HIV/AIDS and aspek psikiatrik

AIDS Care. Author manuscript; available in PMC 2013 Januar 3.

Publishe! in "inal e!ite! "orm as#
AIDS Care. 2011 $ctober; 23%10&# 120'(121'.
Publishe! online 2011 Ma 23. !oi# 10.10'0)0*+,0121.2011.+++-3*
PMCID# PMC3+3,*--
.I/MSID# .I/MS2-3-0*
Somatic Symptoms and the Association
between Hepatitis C Infection and
Depression in HIV-infected Patients
Jeanie C. 0oon1
1
Paul 2. Crane1
1
Paul S. Ciechano3s4i1
1
5obert D. /arrin6ton1
1
Mari M.
2itahata1
1
an! /ei!i M. Crane
1
Author in"ormation 7 Copri6ht an! 8icense in"ormation 7
9he publisher:s "inal e!ite! version o" this article is available at AIDS Care
See other articles in PMC that cite the publishe! article.
;o to#
Abstract
Stu!ies o" !epression an! hepatitis C virus %/C<& in"ection in /I<=in"ecte! patients have
been contra!ictor an! o"ten not a!!resse! 4e !i""erences bet3een /C<=in"ecte! an!
unin"ecte! in!ivi!uals inclu!in6 substance use. 9his cross=sectional observational stu!
"rom the >niversit o" ?ashin6ton /I< Cohort e@amine! associations bet3een /C<1
smptoms1 an! !epression in /I<=in"ecte! patients in routine clinical care. Patients
complete! instruments measurin6 !epression1 smptoms1 an! substance use. ?e
6enerate! !epression severit scores an! use! linear re6ression to e@amine the
relationship 3ith /C< accountin6 "or !emo6raphic an! clinical characteristics. ?e
con!ucte! sensitivit analses in 3hich 3e remove! !epression somatic items %e.6.
"ati6ue& "rom !epression scores1 an! sensitivit analses in 3hich 3e also a!Auste! "or
non=!epression somatic smptom items to e@amine the role o" somatic an! non=somatic
smptoms in the association bet3een !epression an! /C<. $" -B, /I<=in"ecte! patients1
1B0 %21C& 3ere /C<=in"ecte!. In a!Auste! analsis1 /C<=in"ecte! patients ha! 3orse
!epression severit %pD0.01& even a"ter a!Austin6 "or !i""erences in substance use. /C<
remaine! associate! 3ith !epression severit in secon!ar analses that omitte! the
!epression somatic P/E=* items %p D 0.01&. /o3ever1 3hen non=!epression somatic
smptoms 3ere inclu!e! as covariates in multivariate analses1 /C< 3as no lon6er
associate! 3ith !epression %p D 0.0*&.
Conclusions
?e "oun! a hi6h prevalence an! severit o" !epression amon6 /I<=in"ecte! patients in
routine care1 particularl amon6 those 3ith /C<. 9he association bet3een /C< an!
!epression persiste! even 3hen !epression somatic P/E=* items 3ere omitte!
su66estin6 the association 3as not !ue to misclassi"ication o" /C<=relate! somatic
smptoms li4e "ati6ue as !epression. /o3ever1 in mo!els that also a!Auste! "or non=
!epression somatic smptoms1 the association !isappeare! hi6hli6htin6 the stron6
relationship bet3een smptom bur!en an! !epression. 8on6itu!inal stu!ies are nee!e! to
assess the !e6ree smptoms me!iate the association bet3een /C< an! !epression1 an!
3hether increase! smptom bur!en is !ue in part to !epression.
Keywords: hepatitis C virus1 !epression1 /I<1 somatic smptoms1 anti!epressant
me!ications
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I!"#D$C!I#
>n!erstan!in6 the connection bet3een hepatitis C virus %/C<& in"ection an! !epression
in /I<=in"ecte! patients is critical 6iven the e""ect o" !epression on Fualit o" li"e1
a!herence to antiretroviral therap1 an! the !ecision to initiate /C< treatment%Graitstein1
et al.1 200+; Guti1 ?on61 Casa!o1 H Isteban1 200B; Jlemin61 et al.1 200,; 2an3al1 et al.1
200+; Starace1 et al.1 2002&. In the >nite! States1 /C< in"ection is more common amon6
/I<=in"ecte! than unin"ecte! in!ivi!uals 3ith a reporte! prevalence rate bet3een 1B(
3-C%2im1 Psev!os1 Suh1 H Sharp1 200'; Sherman1 5ouster1 Chun61 H 5aAicic1 2002;
Staples1 5imlan!1 H Du!as1 1***&. Previous stu!ies e@aminin6 the occurrence o"
!epressive smptoms in patients co=in"ecte! 3ith /I< an! /C< have pro!uce!
con"lictin6 results 3ith some "in!in6 an association%Gac4us1 Goothro!1 H Deton1 200+;
Gaum1 et al.1 200'; 8ibman1 et al.1 200B; Mrus1 et al.1 200B&1 an! others not%Gaillar6eon1
et al.1 200'; ;rassi1 et al.1 2002; 5ichar!son1 et al.1 200+; 5an1 Mor6ello1 Isaacs1 .aseer1
H ;erits1 200,; 9hein1 et al.1 200-; von ;iesen1 et al.1 200,&. 9hese !i""erent results
mi6ht be e@plaine! b con"oun!in6 "actors1 the use o" !i""erent !epression scales1 small
samples1 an! variable prevalence o" /C< treatment that can itsel" precipitate !epression.
Compare! to /I<=in"ecte! patients 3ithout /C<1 /I< an! /C< co=in"ecte! in!ivi!uals
ten! to be ol!er%Gac4us1 et al.1 200+; 2an3al1 et al.1 200+; Mrus1 et al.1 200B; Staples1 et
al.1 1***; Sul4o3s4i1 Moore1 Mehta1 Chaisson1 H 9homas1 2002&1 an! are more li4el to
be male%Gac4us1 et al.1 200+; 2an3al1 et al.1 200+; 2im1 et al.1 200'&1 A"rican=
American%2an3al1 et al.1 200+; 2im1 et al.1 200'; Staples1 et al.1 1***; Sul4o3s4i1 et al.1
2002& or /ispanic%Gac4us1 et al.1 200+&1 an! to have a histor o" alcohol abuse or illicit
!ru6 use%Gac4us1 et al.1 200+; 2an3al1 et al.1 200+; 2im1 et al.1 200'; Staples1 et al.1
1***; Sul4o3s4i1 et al.1 2002&. Some o" these "actors1 particularl substance use1 are in
turn associate! 3ith !epression%2essler1 et al.1 2003; 8. I. Sullivan1 et al.1 200';
?illiams1 et al.1 200-&1 an! man stu!ies have "aile! to a!Aust "or these con"oun!in6
"actors in the relationship bet3een /C< in"ection an! !epression. ?e con!ucte! this
stu! to e@amine the associations bet3een /C<1 somatic smptoms1 an! !epression in a
lar6e cohort o" /I<=in"ecte! patients in clinical care. ?e hpothesiKe! that /C< 3oul!
be associate! 3ith increase! !epression smptoms even a"ter accountin6 "or substance
use an! 3hen measurement o" !epression !i! not inclu!e somatic smptoms that can be
associate! 3ith both !epression an! /C< such as "ati6ue.
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%&!H#DS
Study settin'
9his cross=sectional stu! 3as con!ucte! on a convenience sample o" patients "rom the
>niversit o" ?ashin6ton %>?& /I< Cohort%/. M. Crane1 et al.1 200-; 2itahata1 et al.1
2003&. 9his stu! receive! Institutional 5evie3 Goar! approval.
Study participants
/I<=in"ecte! patients over 1' ears o" a6e 3ho atten!e! the clinic "or a routine
appointment bet3een 10)1+)200+ an! +)11)200* 3ere eli6ible "or the stu!. Patients
receivin6 inter"eron 3ere e@clu!e! 6iven the 3ell=4no3n e""ect o" inter"eron on
!epressive smptoms.
Data sources
As previousl !escribe!%/. M. Crane1 et al.1 200-&1 patients use! touch=screen tablet PCs
to complete assessments o" !epression smptoms %P/E=* "rom the P5IMI=MD&
%2roen4e1 SpitKer1 H ?illiams1 2001; SpitKer1 2roen4e1 H ?illiams1 1***&1 substance use
%Alcohol1 Smo4in61 an! Substance Involvement Screenin6 9est LASSIS9M&%.e3combe1
/umeniu41 H Ali1 200+; 2002&1 alcohol ris4 %Alcohol >se Disor!ers I!enti"ication 9est
consumption Fuestions LA>DI9=CM&%Gra!le1 et al.1 2003; Gush1 2ivlahan1 McDonell1
Jihn1 H Gra!le1 1**'&1 health=relate! Fualit o" li"e %IuroE$8 +=!imension
Fuestionnaire LIE=+DM&%J. A. Johnson H Coons1 1**'; J. A. Johnson1 Coons1 Ir6o1 H
SKava=2ovats1 1**'; ?u1 et al.1 2002&1 an! smptoms %/I< Smptom In!e@&%Justice1 et
al.1 2001&.
Clinical !ata 3ere obtaine! "rom the >? /I< In"ormation Sstem %>?/IS&1 a
comprehensive !atabase base! on the electronic health recor!s o" patients belon6in6 to
the >? /I< cohort. It inclu!es clinical !ata "rom all outpatient an! inpatient encounters
inclu!in6 !emo6raphic1 clinical1 laborator1 me!ication1 an! socioeconomic in"ormation.
HCV
Patients 3ith positive /C< antibo!1 5.A1 or 6enotpe tests 3ere consi!ere! /C< co=
in"ecte!.
Instrument Scorin'
Stan!ar! P/E=* scores ran6e "rom 0(2- an! are cate6oriKe! as# none %0(, points&1 mil!
%+(* points&1 mo!erate %10(1, points&1 mo!eratel=severe %1+(1*& an! severe %N20
points& !epressive smptom severit%2roen4e1 et al.1 2001&. P/E=* stan!ar! scores have
curvilinear measurement properties 3ith respect to the latent trait o" !epression !e"ine!
b all the items1 meanin6 that a constant !i""erence in score implies !i""erent amounts o"
!epression smptom severit at !i""erent !epression severit levels%P. 2. Crane1 et al.1
2010&. In this situation1 usin6 continuous stan!ar! total scores in re6ressions can lea! to
con"usin6 an! even biase! "in!in6s%P. 2. Crane1 et al.1 200'&. ?e there"ore 6enerate!
scores usin6 item response theor %I59& as !one previousl%P. 2. Crane1 et al.1 2010&; 3e
re"er to these throu6hout as O!epression severit scoresP. I59=base! !epression severit
scores have linear scalin6 properties 3ith respect to the latent trait o" !epression !e"ine!
b all the items%Imbretson H 5eise1 2000&. 9o improve comprehensibilit 3e
trans"orme! !epression severit scores b multiplin6 b 1+ an! a!!in6 100; this results
in rescalin6 scores analo6ous to the IE metric. ?e plotte! a scatterplot sho3in6 the
relationships bet3een stan!ar! P/E=* scores an! I59=base! !epression severit scores.
Previousl1 3e "oun! a notable !i""erences in mean !epression scores bet3een A"rican=
Americans an! 3hites !ue to item=level bias1 re"erre! to as !i""erential item "unctionin6
%DIJ&%P. 2. Crane1 et al.1 2010&. ?e there"ore use! !emo6raphic speci"ic item parameters
to 6enerate scores accountin6 "or DIJ relate! to a6e1 race %A"rican=American vs. 3hite&1
se@1 an! /I< transmission ris4 "actor; "or this analsis 3e omitte! in!ivi!uals 3ho 3ere
neither A"rican=American nor 3hite.
Man prior stu!ies use! !epression measures that inclu!e somatic !epression smptoms
such as "ati6ue an! sleep !isturbance that ma be impacte! b chronic illnesses such as
/C<%D3i6ht1 et al.1 2000; ;olub1 et al.1 200,; /ilsabec41 /assanein1 H Perr1 200+;
8an61 et al.1 200B; McDonal!1 Jaasuria1 Gin!le1 ;onsalveK1 H ;luses4a1 2002;
Per4ins1 et al.1 1**+; Ponar!1 et al.1 2002; P. S. Sullivan H D3or4in1 2003; 9sao1
Dobalian1 Moreau1 H Dobalian1 200,&. 9his raises the Fuestion o" 3hether associations
bet3een /C< an! !epression ma be !ue in part to somatic smptoms associate! 3ith
/C< rather than !epression itsel". ?e thus con!ucte! a sensitivit analsis usin6 a
re!uce! !epression severit score in 3hich 3e remove! the "ati6ue1 loss o" appetite1 an!
sleep !isturbance items "rom the !epression instrument. ?e use! I59 to 6enerate this
re!uce! !epression score.
9he /I< Smptom In!e@ is a measure o" 20 smptom 6roups%Justice1 et al.1 2001&.
Smptom scores 3ere calculate! base! on the number o" smptoms patients in!icate! as
bothersome %e@clu!in6 those smptoms that bothere! the patient onl a little&1 3ith
hi6her scores in!icatin6 6reater smptom bur!en. Jor these analses1 the
!epression)sa!ness smptom item 3as e@clu!e!. ?e also e@amine! smptoms
in!ivi!uall1 cate6oriKin6 each smptom as bothersome or not.
9here are several 3as to score the ASSIS9 to measure substance use%.e3combe1 et al.1
200+; 2002&. ?e 3ere intereste! in an illicit !ru6 use1 current use !e"ine! as an illicit
!ru6 3ithin the prior 3 months1 an! i!enti"in6 in!ivi!ual substance cate6ories %opiates1
amphetamine1 or cocaine)crac4&.
9he A>DI9=C scores "or alcohol use 3ere calculate! b summin6 the scores "or each
A>DI9=C Fuestion %0(, points each&%Gush1 et al.1 1**'&. ?e use! a score o" N+ "or men
an! N, "or 3omen to !e"ine at=ris4 alcohol use%;ual1 Se6ura1 Contel1 /eather1 H Colom1
2002&.
9he IE=+D is a +=item measure o" health=relate! Fualit o" li"e %/5E8&. 9he
combination o" responses cate6oriKes patients into one o" 2,3 uniFue possible health
states. Iach health state is assi6ne! a pre"erence=base! in!e@ score usin6 6eneral
population=base! 3ei6hts%Sha31 Johnson1 H Coons1 200+&.
Statistical Analyses
?e per"orme! bivariate analses comparin6 stu! participant characteristics to the entire
>? /I< cohort usin6 Q
2
tests "or cate6orical variables an! t=tests "or continuous
variables. ?e compare! !emo6raphic an! clinical characteristics b /C< status usin6 Q
2

tests. ?e per"orme! bivariate analses o" associations 3ith !epression severit scores
usin6 t=tests. 9o prevent overestimation o" the prevalence o" smptoms an! behaviors1
missin6 smptom or behavior items 3ere assume! to be absent. ?e use! an impute!
hei6ht base! on a6e1 se@1 an! race "or 1+ in!ivi!uals in 3hom hei6ht 3as missin6. ?e
calculate! bo! mass in!e@ %GMI& usin6 the tra!itional Euetelet in!e@%1**'&. Gaseline
GMI 3as cate6oriKe! as un!er3ei6ht %R1'.+ 46)m
2
&1 normal %1'.+(2,.* 46)m
2
&1
over3ei6ht %2+(2*.* 46)m
2
&1 an! obese %N30 46)m
2
&.
2e variables inclu!e! !epression severit scores1 /C< in"ection1 !emo6raphic
characteristics %a6e1 sel"=reporte! race)ethnicit1 se@1 an! ris4 "actor "or /I<
transmission&1 smptoms1 an! clinical characteristics %CD,
S
cell count na!ir1 current
CD,
S
cell count1 pea4 /I<=1 5.A level1 current antiretroviral therap %A59& use1 current
anti=!epressant me!ication use1 at=ris4 alcohol use1 an or current illicit !ru6 use1 an!
GMI&. ?e use! multivariate linear re6ression to e@amine the relationship bet3een
!epression severit scores an! /C< in"ection accountin6 "or !emo6raphic an! clinical
characteristics.
In a!!ition to the main mo!els1 3e con!ucte! a number o" sensitivit analses. ?e
hpothesiKe! that the e""ect o" /C< on !epression severit scores ma be me!iate!1 in
part1 throu6h somatic !epression smptoms an! there"ore e@clu!e! them "rom the main
mo!els. /o3ever1 somatic smptoms inclu!in6 those not tpicall consi!ere! part o" the
construct o" !epression 3ere inclu!e! as covariates in mo!els "or sensitivit analses as
comparisons o" these results to the main mo!els can help !etermine the e@tent to 3hich
an relationship bet3een /C< an! !epression ma be me!iate! b somatic smptoms.
9o "urther e@plore the potential me!iatin6 relationship o" smptoms1 3e also con!ucte!
a!Auste! analses o" smptoms an! !epressive severit scores e@clu!in6 /C< an! 3e
con!ucte! multivariate lo6istic re6ression analses o" /C< an! in!ivi!ual smptoms. ?e
constructe! !epression severit mo!els that a!Auste! "or /5E8 scores. ?e con!ucte!
sensitivit analses usin6 !epression severit scores a!Auste! "or item=level bias. ?e
con!ucte! sensitivit analses usin6 stan!ar! P/E=* !epression severit scores as the
outcome. ?e con!ucte! analses usin6 stan!ar! P/E=* !epression severit cate6ories
!e"ine! b stan!ar! scores as the outcome; these mo!els emploe! or!inal lo6istic
re6ression. 93o=taile! p values o" R0.0+ 3ere consi!ere! si6ni"icant "or statistical tests.
Analses 3ere con!ucte! usin6 Stata *.2%StataCorp&.
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"&S$(!S
Durin6 the stu! perio!1 the assessment 3as complete! b -B, eli6ible /I<=in"ecte!
patients o" 3hom 1B0 %21C& ha! /C< in"ection %see 9able 1&. $ne patient receivin6
pe6late! inter"eron therap 3as e@clu!e! "rom the stu!. Completion rates 3ere hi6h
3ith minimal missin6 !ata. Missin6 !ata rates "or each smptom item 3ere all R3C1 3ith
the hi6hest rate "or the nausea item %missin6 "or 1*)-B,1 2.+C&. 9here 3ere 2' patients
3ho ha! missin6 !ata "or the A>DI9=C %3.-C&1 an! ,, patients 3ho ha! missin6 !ata "or
an o" the items "or the IuroE$8 %+.BC&. 9he me!ian a6e 3as ,+ ears ol!1 '-C 3ere
men1 the me!ian current CD,
S
9 cell count 3as 3*3 cells)mm
3
1 an! the mean GMI 3as
2B.B 46)m
2
%SD +.0&. At the time o" the assessment1 1-2 patients %23C& 3ere receivin6
anti!epressant me!ications. Demo6raphic an! clinical characteristics o" stu! patients
3ere similar to those o" all patients receivin6 care at the clinic !urin6 the stu! perio!
%!ata not sho3n&.
9able 1
Clinical an! !emo6raphic characteristics o" /I<=in"ecte! stu! patients b /C< status
%.D-B,&
/C<=in"ecte! patients 3ere more li4el to have lo3er na!ir CD,
S
cell counts %3'2 vs.
,33 cells)mm
3
1 p D 0.01&1 to have been inAection !ru6 users %pR0.001&1 an! to report
current illicit !ru6 use 3ithin the past 3 months %pR0.001&. /C<=in"ecte! patients 3ere
more li4el to report ever use an! current use o" cocaine1 amphetamines1 or opiates
compare! 3ith those 3ithout /C< %p values all R0.001&. /C<=in"ecte! patients 3ere also
more o"ten prescribe! anti!epressant me!ication %pD0.03&. 9here 3ere no si6ni"icant
!i""erences bet3een those 3ith /C< in"ection an! those 3ithout in re6ar!s to se@1 a6e1
race)ethnicit1 at=ris4 alcohol use1 GMI1 current CD,
S
count1 an! pea4 /I< viral loa!
%9able 1&.
?e "oun! a hi6h overall smptom bur!en1 3ith patients reportin6 an avera6e o" ,.1
smptoms %SD ,.2&. Jati6ue %,3C& an! sleep !isturbance %3,C& 3ere the most common
smptoms en!orse! %Ji6ure 1&. /C<=in"ecte! patients ha! a hi6her smptom bur!en on
avera6e than those 3ithout /C<1 3ith a smptom score o" ,.' vs. 3.* %pD0.02&.
Ji6ure 1
Prevalence o" mo!erate or severe smptoms amon6 a population o" /I<=in"ecte! patients
%. D -B,&
9he curvilinear relationship bet3een I59 !epression severit scores an! stan!ar! scores
is sho3n in the scatterplot %Ji6ure 2&. 93o hun!re! an! ninet patients %3'C& ha! no
!epression1 20' %2-C& ha! mil!1 12B %1-C& ha! mo!erate1 '2 %11C& ha! mo!eratel=
severe1 an! +' %'C& ha! severe !epression !e"ine! b stan!ar! scores%2roen4e1 et al.1
2001&. Amon6 /C<=in"ecte! patients1 -3 %,BC& 3ere at least mo!eratel !epresse!1
compare! to 1*3 %32C& o" those 3ithout /C< %p D 0.001& %9able 1& an! mean !epression
severit scores 3ere hi6her in /C<=in"ecte! patients %102 vs. *'1 pD0.002&.
Ji6ure 2
Scatter plot an! lo3ess curve o" I59 !epression scores 3ith stan!ar! P/E=* scoresT
Multivariate linear re6ression analses su66este! that /C< in"ection 3as associate! 3ith
hi6her !epression severit scores 3hen controllin6 "or !i""erences in a6e1 se@1 race1 CD,
S
count na!ir1 current CD,
S
count1 A59 status1 current illicit !ru6 use1 at=ris4 alcohol use1
an! GMI. Mean !epression severit scores "or /C<=in"ecte! patients 3ere 3., points
hi6her than "or patients 3ithout /C< in a!Auste! analses %9able 2&. In a!!ition1 hi6her
GMI1 current illicit !ru6 use1 an! at=ris4 alcohol use 3ere associate! 3ith hi6her
!epression severit scores. 9he association bet3een /C< an! 6reater !epression severit
remaine! si6ni"icant in mo!els that also a!Auste! "or anti!epressant me!ication use %S2.*1
pD0.02&1 an! in mo!els that also a!Auste! "or an rather than current illicit !ru6 use %S3.,1
pD0.01&1 or both an an! current illicit !ru6 use %S2.*1 pD0.03&. Jin!in6s 3ere similar in
sensitivit analses usin6 stan!ar! P/E=* scores an! in sensitivit analses usin6 I59
scores that accounte! "or DIJ rather than naUve I59 scores %!ata not sho3n&. /C<
in"ection 3as associate! 3ith more severe !epression severit cate6or in sensitivit
analses usin6 or!inal lo6istic re6ression 3ith stan!ar! P/E=* score=base! !epression
smptom severit cate6ories%2roen4e1 et al.1 2001&%9able 3&. /C< in"ection remaine!
associate! 3ith more severe !epression in multivariate analses usin6 re!uce! !epression
severit scores constructe! "rom the B non=somatic P/E=* items %S3.11 pD0.01&.
9able 2
Chan6e in !epression severit scores amon6 /I<=in"ecte! patients in routine clinical care
usin6 multivariate linear re6ression %.D-B,&
9able 3
A!Auste! o!!s ratios "or more severe !epression cate6ories usin6 multivariate or!inal
lo6istic re6ression amon6 /I<=in"ecte! patients in routine clinical care %.D-B,&
9o e@amine 3hether somatic smptoms inclu!in6 smptoms not tpicall consi!ere! part
o" the !epression construct coul! potentiall be me!iatin6 the association bet3een /C<
an! !epression severit scores usin6 a classic approach %Ji6ure 3&%Garon H 2enn1
1*'B&1 3e "irst !emonstrate! that /C< 3as associate! 3ith overall smptom bur!en
scores %pD0.0,& in a!Auste! analses. Jurthermore1 /C< 3as also associate! 3ith a
number o" in!ivi!ual smptoms particularl memor problems1 poor appetite1 an! nausea
%p values 0.00B(0.03&. ?e then !emonstrate! in a!Auste! mo!els 3ithout /C<1 that
hi6her overall smptom bur!en 3as associate! 3ith more severe !epression severit
scores %pR0.001&. In mo!els 3ith in!ivi!ual smptoms rather than overall smptom
bur!en1 memor problems1 poor appetite1 "ati6ue1 "evers1 an@iet1 sleep !isturbance1
se@ual !s"unction1 an! 3ei6ht loss 3ere all associate! 3ith more severe !epression
smptom severit %p valuesR0.001(0.00-&. Jinall1 3e e@amine! the association bet3een
/C< an! !epression severit scores in a!Auste! mo!els that inclu!e! in!ivi!ual somatic
smptoms or overall smptom bur!en scores. ?hen somatic smptoms 3ere inclu!e! as
in!ivi!ual covariates or as overall smptom bur!en1 /C< in"ection 3as no lon6er
si6ni"icantl associate! 3ith hi6her !epression severit scores %p values 0.0*(0.1&.
Jati6ue1 subAective "evers1 memor problems1 an@iet1 !ecrease! appetite1 sleep
!isturbance1 se@ual !s"unction1 an! 3ei6ht loss 3ere si6ni"icantl associate! 3ith
!epression severit scores in a!Auste! mo!els that inclu!e! all smptoms. Depression
severit scores constructe! "rom the B non=somatic P/E=* items 3ere associate! 3ith the
same smptoms. .ausea1 !iKKiness1 an! musculos4eletal pains 3ere not associate! 3ith
!epression severit an! 3ere !roppe! "rom subseFuent analses.
Ji6ure 3
Me!iatin6 role o" smptoms in the association bet3een /C< in"ection an! !epression
smptoms severit
9he mean IuroE$8 score "or the entire stu! cohort 3as 0.'0 %SD 0.1*&. /C<=in"ecte!
patients ha! 3orse /5E81 3ith mean IuroE$8 score o" 0.-B in /C<=in"ecte! patients
vs. 0.'1 in patients 3ithout /C< in"ection %pD0.01&. A"ter accountin6 "or clinical an!
!emo6raphic characteristics %a6e1 race1 se@1 recent illicit !ru6 use1 na!ir an! recent CD,
S

counts an! A59 status&1 the association bet3een /C< in"ection an! /5E8 3as no lon6er
si6ni"icant %pD0.0-&.
;o to#
DISC$SSI#
?e "oun! a hi6h prevalence an! severit o" !epression amon6 /I<=in"ecte! patients in
routine care; particularl amon6 those co=in"ecte! 3ith /C<. 9he association bet3een
/C< an! !epression severit persiste! 3hen omittin6 somatic !epression smptom items
"rom the !epression measure. /o3ever1 the association 3as not seen in a!Auste! analses
that inclu!e! somatic smptoms as covariates. Increase! GMI1 current illicit !ru6 use1
an! at=ris4 alcohol use 3ere also consistentl associate! 3ith 6reater !epression severit.
/C< in"ection is associate! 3ith !epression in those 3ithout /I< in"ection%el=Sera61
2uni41 5ichar!son1 H 5abenec41 2002; ;alle6os=$roKco1 et al.1 2003; ;oul!in61
$:Connell1 H Murra1 2001; M. I. Johnson1 Jisher1 Jenau6ht1 H 9heno1 1**'; 8im1
Cron4ite1 ;ol!stein1 H Cheun61 200B; $bhrai1 /all1 H Anan!1 2001; Sin6h1 ;ao3s4i1
?a6ener1 H Marino1 1**-&. /o3ever1 there are con"lictin6 !ata re6ar!in6 the association
bet3een /C< an! !epression in /I<=in"ecte! patients%Gac4us1 et al.1 200+; Gaillar6eon1
et al.1 200'; Gaum1 et al.1 200'; ;rassi1 et al.1 2002; 8ibman1 et al.1 200B; Mrus1 et al.1
200B; 5ichar!son1 et al.1 200+; von ;iesen1 et al.1 200,&. $ur stu! supports an
association bet3een /C< an! 6reater !epression severit. $ur conclusions are robust to
several scorin6 metho!s inclu!in6 I59 estimates o" !epression severit "rom the 3hole
scale an! the non=somatic items1 an! !epression cate6ories an! continuous scores !e"ine!
usin6 stan!ar! scorin6. Jurthermore1 !espite hi6h prevalence rates o" !epression amon6
patients 3ith substance use issues1 an! a hi6h prevalence o" substance use amon6 patients
3ith /C<1 3e "oun! that the association bet3een /C< an! 6reater !epression severit
persiste! in numerous sensitivit analses a!Austin6 "or current substance use1 past
substance use1 or both.
Somatic smptoms such as "ati6ue an! sleep !isturbance ma be !ue to !epression as
3ell as to chronic illnesses inclu!in6 /I< or /C< in"ection thereb obscurin6
e@amination o" associations bet3een /C< in"ection an! !epression%McDonal!1 et al.1
2002; Per4ins1 et al.1 1**+; P. S. Sullivan H D3or4in1 2003; 9sao1 et al.1 200,&. Stu!ies
have su66este! that !epression associate! 3ith /C< in"ection in /I<=in"ecte! patients
ma be attributable to somatic smptoms such as "ati6ue. Jor e@ample1 Graitstein an!
collea6ues an! Cli""or! an! collea6ues "oun! that /I<=in"ecte! patients 3ith /C< ha!
hi6her CIS=D somatic scores than those 3ith /I< 3ithout /C< in"ection%Graitstein1 et
al.1 200+; Cli""or!1 Ivans1 0an61 H ;ulic41 200+&. In our analses1 inclu!in6 or e@clu!in6
the somatic !epression smptom items in I59 !epression severit scores !i! not
substantiall impact the stren6th o" association bet3een /C< an! !epression. 9his
su66ests that the association bet3een /C< an! !epression is not simpl !ue to the
patients meetin6 the clinical criteria "or !epression !ue to /C<=relate! somatic
smptoms. .evertheless1 this "in!in6 !oes not e@clu!e the possibilit that /C<=relate!
smptoms ma be on a causal path3a lea!in6 to !epression.
9o "urther un!erstan! the potential role o" somatic smptoms in possibl me!iatin6 the
relationship bet3een /C< an! !epression amon6 /I<=in"ecte! patients1 3e e@amine! the
association bet3een /C< an! !epression severit in mo!els that inclu!e! in!icators "or
overall smptom bur!en or in!ivi!ual smptoms inclu!in6 those not consi!ere! part o"
the !epression construct. In these mo!els there 3as no lon6er an association bet3een
/C< an! !epression1 su66estin6 that /C<=relate! somatic smptoms ma me!iate the
relationship bet3een /C< in"ection an! !epressive smptom severit. It ma be that
somatic smptoms associate! 3ith /C< cause !epression. Alternativel1 !epresse!
patients ma have a hei6htene! a3areness o" smptoms !ue to their !epression an! the
association o" /C< an! !epression ma in part be me!iate! b other "actors. $nl
lon6itu!inal stu!ies can !istin6uish bet3een these alternative e@planations.
Potential limitations o" our stu! inclu!e the reliance on sel"=reporte! !ata "or some
variables1 an! the use o" a convenience sample o" patients 3ho complete! the assessment1
althou6h our sampleVs !emo6raphic an! clinical characteristics 3ere similar to the entire
cohort. A!!itionall1 the P/E=* Fuestionnaire 3as not !esi6ne! as a !ia6nostic tool
althou6h its vali!it has been evaluate! previousl1 !emonstratin6 6oo! a6reement 3ith
!ia6noses ma!e b mental health pro"essionals%SpitKer1 et al.1 1***; SpitKer1 et al.1 1**,&.
/C< co=in"ecte! patients coul! have been misclassi"ie! !ue to "alse ne6ative /C<
antibo! tests or positive tests !espite spontaneous /C< clearance. .e6ative /C<
antibo! test results amon6 /C< co=in"ecte! patients occur1 ho3ever it is
uncommon%Jorns H Costa1 200B&1 an! spontaneous /C< clearance rates are lo3er
amon6 those 3ith /I< than the 6eneral population%;rebel1 et al.1 200-&. Jurthermore1
13* o" the 1B0 patients ha! a positive /C< 5.A test. 9he cross=sectional nature o" the
stu! limits our abilit to in"er causal relationships in the association bet3een /C< an!
!epression. In a!!ition1 patients 3ere recruite! "rom a sin6le lar6e /I< clinic1 so our
"in!in6s ma not be 6eneraliKable to all /I<=in"ecte! patients1 especiall those not in
care.
Stren6ths o" our stu! inclu!e the relativel lar6e an! !iverse stu! population an!
stan!ar!iKe! !epression assessment. In a!!ition1 comprehensive clinical !ata "acilitate!
a!Austment "or 4e potential con"oun!in6 "actors such as current an! past illicit !ru6 use1
at=ris4 alcohol use1 CD,
S
cell count na!ir1 an! current A59 use. Jurthermore1 unli4e
some previous stu!ies%121 221 ,B1 B3&1 3e avoi!e! possible selection bias relate! to
recruitment o" patients "rom treatment trials1 3hich ten! to e@clu!e patients 3ith on6oin6
!ru6 use or mental illness1 or inclu!e patients 3ith onl more severe /C< !isease.
In summar1 3e "oun! hi6h rates o" !epression in /I<=in"ecte! patients in routine care1
particularl amon6 those 3ith /C< in"ection. 9he association bet3een /C< an! 6reater
!epression severit persiste! even a"ter ta4in6 into account associations bet3een past or
current substance use an! !epression severit. 9hese "in!in6s su66est that there is an
in!epen!ent association bet3een /C< an! !epression severit above an! beon! an
associations !ue to substance use. 9he association bet3een /C< an! !epression persiste!
even 3hen the !epression measure e@clu!e! somatic items su66estin6 this association is
not !ue to a mis=attribution o" /C<=relate! somatic complaints to3ar! the !ia6nosis o"
!epression. Provi!ers shoul! be alert to the hi6h rates o" !epression amon6 /I<=in"ecte!
patients in routine clinical care1 particularl amon6 those 3ith /C<. Jurther lon6itu!inal
stu!ies are nee!e! to !etermine the casual role o" /C< an! /C<=relate! somatic
smptoms in the !evelopment o" !epression.
;o to#
ACK#)(&D*&%&!S
?e 3ish to than4 the patients an! provi!ers o" the >niversit o" ?ashin6ton Ma!ison
/I< clinic. 9his 3or4 3as supporte! b 6rants "rom the Mentore! Patient=$riente!
5esearch Career Development A3ar! .IAID ;rant %AI=B0,B,&1 the .I/ .IM/ 5$1
6rant %5$1M/0',-+*&1 the CJA5=.et3or4 o" Inte6rate! Clinical Sstems %C.ICS&
%.I/ 52, AI0B-03*&1 an! the >niversit o" ?ashin6ton Center "or AIDS 5esearch
.IAID ;rant %AI2--+-&.
;o to#
A++"&VIA!I#S
/C<
/epatitis C virus
A59
antiretroviral therap
>?
>niversit o" ?ashin6ton
>?/IS
>? /I< In"ormation Sstem
P/E
patient health Fuestionnaire
P5IMI=MD
Primar Care Ivaluation o" Mental Disor!ers
I59
item response theor
/5E8
health=relate! Fualit o" li"e
;o to#
,ootnotes
Data "rom this stu! 3as presente! in part at the International ?or4shop on /I<
$bservational Databases1 Sit6es1 Spain1 March 2010.
9he enclose! article has not been publishe! an! is not un!er consi!eration "or publication
else3here.
;o to#
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P5IMI=MD 1000 stu!. JAMA. 1**,;2-2%22&#1-,*(1-+B. LPubMe!M
+1. Staples C91 Jr1 5imlan! D1 Du!as D. /epatitis C in the /I< %human
immuno!e"icienc virus& Atlanta <A %<eterans A""airs Me!ical Center& Cohort
Stu! %/A<ACS&# the e""ect o" coin"ection on survival. Clin In"ect Dis.
1***;2*%1&#1+0(1+,. LPubMe!M
+2. Starace J1 Ammassari A1 9rotta MP1 Murri 51 De 8on6is P1 IKKo C1 et al.
Depression is a ris4 "actor "or suboptimal a!herence to hi6hl active antiretroviral
therap. J AcFuir Immune De"ic Sn!r. 2002;31%Suppl 3&#S13B(S13*. LPubMe!M
+3. StataCorp. Stata Statistical So"t3are %<ersion *.2& Colle6e Station1 9e@as#
StataCorp.;
+,. Sul4o3s4i MS1 Moore 5D1 Mehta S/1 Chaisson 5I1 9homas D8. /epatitis C
an! pro6ression o" /I< !isease. JAMA. 2002;2''%2&#1**(20B. LPubMe!M
++. Sullivan 8I1 SaitK 51 Chen6 DM1 8ibman /1 .unes D1 Samet J/. 9he impact o"
alcohol use on !epressive smptoms in human immuno!e"icienc virus=in"ecte!
patients. A!!iction. 200';103%*&#1,B1(1,B-. LPMC "ree articleM LPubMe!M
+B. Sullivan PS1 D3or4in MS. Prevalence an! correlates o" "ati6ue amon6 persons
3ith /I< in"ection. J Pain Smptom Mana6e. 2003;2+%,&#32*(333. LPubMe!M
+-. 9hein /1 Maru"" P1 2rahn M1 2al!or J1 2oore D1 Gre3 G1 et al. Co6nitive
"unction1 moo! an! health=relate! Fualit o" li"e in hepatitis C virus %/C<&=
monoin"ecte! an! /I<)/C<=coin"ecte! in!ivi!uals commencin6 /C< treatment.
/I< Me!. 200-;'%3&#1*2(202. LPubMe!M
+'. 9sao JC1 Dobalian A1 Moreau C1 Dobalian 2. Stabilit o" an@iet an! !epression
in a national sample o" a!ults 3ith human immuno!e"icienc virus. J .erv Ment
Dis. 200,;1*2%2&#111(11'. LPubMe!M
+*. von ;iesen /J1 /eint6es 91 Abbasi=Gorou!Aeni .1 2ucu44olu S1 2oller /1
/aslin6er GA1 et al. Pschomotor slo3in6 in hepatitis C an! /I< in"ection. J
AcFuir Immune De"ic Sn!r. 200,;3+%2&#131(13-. LPubMe!M
B0. ?/$ ASSIS9 ?or4in6 ;roup. 9he Alcohol1 Smo4in6 an! Substance
Involvement Screenin6 9est %ASSIS9&# !evelopment1 reliabilit an! "easibilit.
A!!iction. 2002;*-%*&#11'3(11*,. LPubMe!M
B1. ?illiams D51 ;onKaleK /M1 .ei6hbors /1 .esse 51 Abelson JM1 S3eetman J1 et
al. Prevalence an! !istribution o" maAor !epressive !isor!er in A"rican Americans1
Caribbean blac4s1 an! non=/ispanic 3hites# results "rom the .ational Surve o"
American 8i"e. Arch ;en Pschiatr. 200-;B,%3&#30+(31+. LPubMe!M
B2. ?u A?1 Jacobson 281 Jric4 2D1 Clar4 51 5evic4i DA1 Jree!ber6 2A1 et al.
<ali!it an! responsiveness o" the euroFol as a measure o" health=relate! Fualit
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2'2. LPubMe!M
Jurnal 2
HIV Ther. Author manuscript; available in PMC 2011 March 1.
Published in nal edited !orm as"
HIV Ther. 2010 Ma#; $%&'" &(1)&(*.
doi" 10.221(+hiv.10.2&
PMCI," PMC2*&&1(1
-IHM.I," -IHM.20(2$/
Comparison of scales to e-aluate the
pro'ression of HIV-associated
neuroco'niti-e disorder
-ishiena . 0andhi1
112
3ichard T Mo4le#1
1
5ason Crei6hton1
1
Heidi Vornbroc7
3oosa1
1
3ichard 8 .7olas7#1
2
9la A .elnes1
1
5ustin McArthur1
1
and -ed .ac7tor
1
Author in!ormation : Cop#ri6ht and 8icense in!ormation :
.ee other articles in PMC that cite the published article.
0o to"
Abstract
Aim
Jirst1 to compare the characteriKation o" neuroco6nitive !e"icits in mil!er sta6es o" /I<=
associate! neuroco6nitive !isor!er %/A.D& !erive! "rom e@istin6 !ementia ratin6 scales
o" the American Aca!em o" .eurolo6 %AA.& an! Memorial Sloan 2etterin6 %MS2&
3ith the 200- consensus %[JrascatiV& classi"ication. Secon!1 to i!enti" potential
socio!emo6raphic an! clinical pre!ictors o" /A.D pro6ression !urin6 1=ear "ollo3=up.
%ethods
10, /I<=in"ecte! subAects in an e@istin6 cohort sstem 3ere evaluate! 3ith a me!ical
histor1 e@am1 neuropscholo6ical test batter an! "unctional assessments. 9he !e6ree o"
/A.D 3as rate! usin6 the AA.1 MS2 an! Jrascati scales. 9he !e6ree o" concor!ance
amon6 these scales 3as !etermine!. In a!!ition1 ,+ subAects 3ere reassesse! "or chan6es
in their neuroco6nitive status at 1=ear "ollo3=up. Associations bet3een a6e1 e!ucation1
se@1 !epression ratin6s1 substance abuse1 race1 hepatitis C serostatus1 CD, count an!
pro6ression o" /A.D 3ere e@amine!.
"esults
9here 3as e@cellent concor!ance %\ ] 0.'& amon6 the Jrascati1 MS2 an! AA. ratin6s.
SubAects rate! as havin6 minor co6nitive motor !isor!er on the AA. scale %n D ,+& 3ere
evenl split bet3een Jrascati ratin6 o" asmptomatic neuroco6nitive impairment %n D 2,&
an! mil! neuroco6nitive !isor!er %n D 21&. At 1=ear "ollo3=up o" ,+ subAects1 31C ha!
3orsene!1 13C ha! improve! an! +BC 3ere stable. Pre!ictors o" pro6ression inclu!e!
a6e ol!er than +0 ears %o!!s ratio# +.+-; p D 0.013& an! "emale 6en!er %o!!s ratio# 3.13;
p D 0.03B&.
Conclusion
9he Jrascati /A.D ratin6 scale has e@cellent concor!ance 3ith previous neuroco6nitive
ratin6 scales an! can be use! to better characteriKe mil!er sta6es o" co6nitive impairment.
$l!er in!ivi!uals an! 3omen appeare! to be more li4el to sho3 neuroco6nitive
pro6ression.
Keywords: dementia ratin6 scales1 ;rascati1 HIV1 HIV<associated
neuroco6nitive disorders1 pro6ression
$ne o" the earlier scales use! to !ia6nose /I<=associate! neuroco6nitive !isor!ers
%/A.D& 3as the Memorial Sloan 2etterin6 %MS2& scale1 3hich contains 6ra!ations that
ran6e "rom minor co6nitive !isturbance to pro"oun! an! incapacitatin6 !isor!ers L1M.
/o3ever1 the scales inte6rate neurolo6ical !e"icits relate! to melopath1 "ocusin6 on
ambulator "unction. ?hile this scale has been use"ul in man conte@ts it !oes not
a!eFuatel separate the co6nitive an! behavioral impairments ori6inatin6 "rom brain
!isease speci"icall "rom melopathic impairments.
In 1**1 the American Aca!em o" .eurolo6 %AA.& !etaile! criteria "or !e"inin6
!i""erent levels o" /A.D in research stu!ies an! clinical practice L2M. 9he 1**1 criteria
!escribe! t3o levels o" co6nitive impairment# minor co6nitive motor !isor!er %MCMD&
an! the more severe /I<=associate! !ementia %/AD&. MCMD 3as !e"ine! to encompass
less pro"oun! "orms o" co6nitive motor an! other behavioral !s"unction.
In 200-1 a revise! classi"ication 3as propose! b a 3or4in6 6roup assemble! in Jrascati1
Ital1 3hich aime! to cate6oriKe the presentation o" neuroco6nitive !isturbances in the
post=/AA59 era1 3hich is characteriKe! b persistence o" primaril mil!er "orms o"
neuroco6nitive !isturbance. 9he [JrascatiV criteria emphasiKes that the essential "eature o"
/A.D is co6nitive !isturbance; this revision eliminate! the possibilit o" /I<
neuroco6nitive !isor!ers bein6 !ia6nose! on the basis o" neuromotor an! nonco6nitive
pschiatric chan6es such as chan6es in personalit or moo!. More precise criteria "or
three sn!romes 3ithin the "rame3or4 o" /A.D 3ere establishe!# asmptomatic
neuroco6nitive impairment %A.I&1 mil! neuroco6nitive !isor!er %M.D& an! /AD.
Speci"icall1 the intro!uction o" the terms A.I an! M.D 3ere propose! to better
characteriKe the neuroco6nitive !e"icits seen 3ithin mil!er sta6es o" /A.D L3M.
Man in!ivi!uals 3ith /A.D remain neuro lo6icall stable a"ter startin6 /AA591 or
ma sho3 partial reversal o" neurolo6ical !e"icits. /o3ever1 there is a subset o"
in!ivi!uals 3hose neuroco6nitive "unction continues to !ecline !espite antiretroviral
treatment L,(BM. Goth !emo6raphic an! me!ical "actors ma pla a role in this
pro6ression1 3hich1 i" reco6niKe!1 mi6ht tri66er !i""erent strate6ies o" antiretroviral or
a!Aunctive therapies.
Previous stu!ies have mostl loo4e! "or pre!ictive "actors associate! 3ith a ris4 o"
!evelopin6 /AD rather than pro6ression throu6h various hierarchical levels o"
neuroco6nitive !s"unction L-(*M.
9he current stu! 3as !esi6ne! to e@amine the concor!ance bet3een the Jrascati scale
an! t3o other scales; the MS2 scale an! the AA. scale. 9he Jrascati scale has more
precise !eline= !elineation o" neuroco6nitive impairment in mil!er sta6es o" this !isease
an! ma thus be more sensitive to neurolo6ical pro6ression in /AA59=e@perience! /I<=
in"ecte! in!ivi!uals. ?e thus evaluate! the pre!ictive in"luence o" baseline
socio!emo6raphic an! clinical characteristics on pro6ression o" /A.D usin6 this ne3er
scale.
0o to"
%ethods
Participants
9he stu! inclu!e! 10, /I<=in"ecte! in!ivi!uals at the ;eneral Clinical 5esearch Clinic
at Johns /op4ins /ospital in Galtimore1 MD1 >SA1 3ho 3ere evaluate! "rom 200- to
200*. 9he stu! 3as approve! b the Johns /op4ins Institutional 5evie3 Goar!. /I<=
in"ecte! patients 3ere recruite! "rom t3o cohorts; the .ortheast AIDS Dementia %.IAD&
cohort L10M an! the $@i!ative Stress Cohort L11M1 an! 3ere chosen usin6 the "ollo3in6
inclusion criteria# a!ults ol!er than 1' ears o" a6e1 /I<=1=seropositive status1 abilit to
provi!e 3ritten in"orme! consent1 an! abilit to ambulate at "irst clinic visit. I@clusion
criteria 3ere the "ollo3in6# histor or current opportunistic C.S in"ection1 histor o" or
current schiKophrenia1 current severe a""ective !isor!er believe! to e@plain subAectVs
co6nitive impairment1 an! histor o" chronic neurolo6ical !isor!ers such as epileps or
multiple sclerosis. Substance abusers an! heav alcohol users1 remote or active1 3ere not
e@clu!e! but 3ere not e@amine! i" Au!6e! b the e@aminer to be into@icate! !urin6 the
visit
?ritten in"orme! consent 3as obtaine! "rom all patients participatin6 in the stu!.
.uestionnaires
Iver B to 12 months subAects un!er3ent the "ollo3in6# stan!ar!iKe! Fuestionnaires 3ere
use! to capture me!ical in"ormation an! !emo6raphics1 alon6 3ith me!ical1 pschiatric
an! neurolo6ical histor. A !etaile! substance abuse Fuestionnaire 3as also sel"=
a!ministere!. SubAects 3ere as4e! to report their current amount o" alcohol inta4e an!
3hether the use! cocaine an!)or heroin in the past B months.
Clinical e/am
SubAects un!er3ent a clinical e@amination consistin6 o" a macroneurolo6ic e@amination
create! "or the AIDS Clinical 9rials ;roup %AC9;& an! the motor subscale %part III& o"
the >ni"ie! Par4insonVs Dementia 5atin6 Scale %>PD5S& L12M1 to assess e@traprami!al
si6ns associate! 3ith /AD.
Depression assessment
Moo! 3as assesse! 3ith the sel"=a!ministere! Gec4 Depression Inventor %GDI&. A score
6reater than or eFual to 1B 3as !e"ine! as the presence o" !epression smptomatolo6.
(aboratory assessment
CD,
S
lmphocte count an! levels o" /I< 5.A in cerebrospinal "lui! %CSJ& an! plasma
3ere obtaine!. /I< 5.A levels 3ere !etermine! usin6 the 5oche PC5 assa %Amplicor
/I<=1 Monitor assa1 version 1.+; 5oche Dia6nostics1 Gasel1 S3itKerlan!&. /epatitis C
viral status 3as obtaine! via histor an! evaluation o" laborator "in!in6s "or /C<
antibo!ies.
Dia'nosis of HAD
Dementia assessment 3as per"orme! accor!in6 to the ori6inal AA. classi"ication an!
MS2 sta6in6 classi"ication usin6 previousl publishe! metho!olo6 "or neuroco6nitive
testin6 an! !e"inition o" "unctional impairment L13M. .europscholo6ical !omains teste!
3ere# attention an! 3or4in6 memor %usin6 ComputeriKe! 5eaction 9ime 9est&1 verbal
memor %usin6 5e Au!itor <erbal 8earnin6 9est&1 visual memor an! visuo=
construction %usin6 5e Comple@ Ji6ure 9est&1 pschomotor an! motor spee! %usin6
Smbol Di6it Mo!alities 9est1 9railma4in6 9est A H G1 ;roove! Pe6boar! 9est an!
9ime! ;ait&1 "rontal)e@ecutive "unctionin6 %usin6 <erbal Jluenc 9est an! $!! Man $ut&
an! literac %usin6 .ational A!ult 5ea!in6 9est&. Junctional assessment 3as per"orme!
usin6 the 2arno"s4 Per"ormance Scale1 Instrumental Activities o" Dail 8ivin6 %IAD8&
assessment an! subAective "unctional complaints. In a!!ition1 ne3 outcomes !evelope! in
the 200- Jrascati consensus classi"ication 3ere also assi6ne! b the same stu! team L3M.
Data analyses
9he primar outcomes "or this stu! 3ere neuroco6nitive status usin6 the previousl
mentione! three classi"ications at baseline visit. Concor!ance bet3een MS2 an! both
AA. ratin6 an! Jrascati ratin6 scales 3ere teste! usin6 the ;oo!man(2rus4al \ statistic
L1,M. 9he ;oo!man(2rus4al \ statistic is !e"ine! as the !i""erence bet3een the
probabilit o" 6ettin6 a concor!ant pair an! that o" 6ettin6 a nonconcor!ant pair1
con!itional on all such concor!ant an! nonconcor!ant pairs. 9he ;oo!man(2rus4al \
statistic ran6es bet3een S1 an! ^1. I" the t3o ratin6 scales are in!epen!ent o" one
another1 \ 3oul! eFual 0. A positive \ statistic means that 3e are more li4el to obtain
concor!ant pairs than !iscor!ant ones1 Similarl1 a ne6ative \ statistic implies that
subAects 3ith lar6er scores on one scale %e.6.1 Jrascati& are more li4el to be associate!
3ith smaller scores on the other scale %e.6.1 MS2&.
A subset o" ,+ /I<=in"ecte! in!ivi!uals 3as assesse! at 1 ear "ollo3in6 baseline.
Chan6e in the Jrascati ratin6 3as use! to !ocument pro6ression o" /A.D !urin6 this
time perio!. 9o analKe variables as pre!ictors o" chan6e in co6nitive status1 associations
bet3een the in!epen!ent socio!emo6raphic characteristics measure! at baseline %a6e N
+0 ears1 race1 colle6e e!ucation1 6en!er1 clinical !epression per GDI1 substance abuse
histor1 hepatitis C status an! CD, count less than 200 cells)mm
3
& an! chan6e in
co6nitive status %improve!1 stable or 3orse& 3ere e@amine! usin6 a poltomous lo6istic
re6ression mo!el L1+M. 9his mo!el 3as "it usin6 SAS P5$C CA9M$D.
0o to"
"esults
Study demo'raphics
In 9able 11 there is a summar o" the !emo6raphics o" the total 10, /I<=in"ecte! patients
evaluate! in this stu! an! then sub!ivi!e! b Jrascati ratin6 o" co6nitive status. 9he
mean a6e 3as ,B.* ears %stan!ar! !eviation LSDM D B.,&. A maAorit o" the patients
%-2C& 3ere men. Mean CD,
S
9=cell count 3as 3+, cells)mm
3
%SD D 20B.+&. Depression
base! on a GDI score 6reater than or eFual to 1B 3as "oun! in 22.1C o" /I<=in"ecte!
patients in this stu!. A maAorit o" patients %+'.-C& 3ere seropositive "or /C<. .o
si6ni"icant !i""erences bet3een the !ementia ratin6 sub6roups 3ere seen in these
!emo6raphics. Ji6ure 1 illustrates the !istribution o" neuroco6nitive !ia6noses accor!in6
to the Jrascati1 AA. an! MS2 ratin6 scales.
;i6ure 1
Distribution of neurocognitie diagnoses according to !rascati"
asy#pto#atic neurocognitie i#pair#ent and $e#orial Sloan
Kettering ratings
Table 1
,emo6raphics !or the total clinical outcomes cohort and ;rascati ratin6s.
Concordance between ratin' scales
9he concor!ance bet3een the Jrascati an! MS2 scales 3as e@cellent %;oo!man(2rus4al
\ D 0.*B*& %9able 2&. /o3ever1 there 3ere some cases 3here there 3as !i""erential ratin6.
Jor instance1 32 out o" the ++ cases o" MS2 0.+ !e"ine! as subclinical)eFuivocal
!ementia 3ere rate! as Jrascati A.I.
Table 2
Concordance bet=een ;rascati and Memorial .loan >etterin6 ratin6 scale
2
.
Comparin6 the Jrascati ratin6 an! AA. ratin6 scales1 3e a6ain "oun! that there 3as
e@cellent concor!ance %;oo!man(2rus4al \ D 0.*B0& %9able 3&. 9hose cases that 3ere
rate! as MCMD on the AA. scale %n D ,+& 3ere split appro@imatel evenl bet3een A.I
an! M.D on the Jrascati scale. 9en in!ivi!uals 3ho 3ere consi!ere! normal un!er the
AA. ratin6 scale "ell 3ithin the A.I cate6or in the ne3 Jrascati ratin6.
Table &
Concordance bet=een ;rascati and American Academ# o! -eurolo6# ratin6
scale
2
.
Predictors of HAD pro'ression
$" the ori6inal 10, enrolle!1 ,+ patients ha! a "ollo3=up e@amination 3ithin 1 ear.
$thers 3ere seen at !i""erent time intervals so 3e e@clu!e! them "rom this ana lsis to
ensure 3e ha! consistenc 3ith re6ar! to the time elapse! "rom baseline to !etermine
pro6ression o" /A.D. $" the ,+ patients1 32 %-1C& 3ere men1 3hich 3as not
si6ni"icantl !i""erent "rom the total cohort. $" the ,+ patients1 1, %31C& sho3e! !eclines
in neuroco6nitive "unction1 2+ %+BC& 3ere stable an! si@ %13C& sho3e! improve!
"unction at 1=ear "ollo3=up relative to their baseline neuro co6nitive status. Gase! on
poltomous lo6istic re6ression1 in!ivi!uals 3ith an a6e 6reater than or eFual to +0 ears
3ere more li4el to !emonstrate neuroco6nitive !ecline compare! 3ith those 3ith an a6e
oun6er than +0 ears %o!!s ratio L$5M# +.+-; *+C CI# 1.,,(21.+3; p D 0.013&1 a"ter
a!Austin6 "or colle6e e!ucation1 6en!er1 race1 !epression smptoms1 substance abuse1
hepatitis C status an! CD,
S
cell count less than 200 cells)mm
3
. In the same mo!el1
3omen 3ere more li4el to !emonstrate 3orsenin6 o" neuroco6nitive status compare!
3ith men %$5# 3.13; *+C CI# 1.0'(*.0*; p D 0.03B& %9able ,&. $3in6 to this "in!in61 3e
strati"ie! the !emo6raphic an! clinical !ata b 6en!er. In this subset o" ,+ "ollo3=up
visits1 o" the 1+ people a6e! +0 ears or 6reater1 "our %2-C& 3ere 3omen. $" the 30
people a6e! un!er +0 ears1 nine %30C& 3ere 3omen. 9here 3as no !i""erence in
!istribution o" 6en!er bet3een these t3o a6e 6roups %p D 0.'1B&. ?omen1 ho3ever1 ha!
si6ni"icantl "e3er ears o" e!ucation %11.'3 vs 13.1+ ears; p D 0.00B& an! hi6her CD,
S

cell counts %,B1.1- vs 312.2- cells)mm
3
; p R 001& compare! 3ith men.
Table $
,ecline or improvement o! neuroco6nitive status as a !unction o!
sociodemo6raphic and clinical characteristics.
0o to"
Discussion
9he AIDS 9as4 Jorce o" the AA. publishe! nomenclature an! research case !e"initions
to 6ui!e the !ia6nosis o" neurolo6ic mani"estations o" /I<=1 in"ection in 1**1 L2M. 9he
!i""erent levels o" /A.D the !escribe! subseFuentl became 4no3n as the [AA. ratin6
scaleV.
A"ter the intro!uction o" /AA59 in 1**B1 the inci!ence o" /AD !ecline! alon6 3ith
most other /I<=associate! comorbi!ities L1BM. In a stu! b one o" the authors1 the
inci!ence o" mo!erate or severe !ementia "ell "rom appro@imatel -C in 1*'* to onl 1C
in 2000 L1BM. /AA59 3as "oun! to improve co6nitive per"ormance in some patients L'M1
an! patients coul! survive "or ears 3ith /A.D. In 20001 appro@imatel +(10C o" /I<=
in"ecte! in!ivi!uals 3ith a!vance! in"ection ha! /AD an! appro@imatel 3-C ha! less
severe "orms o" /A.D L1BM. 9he prevalence o" /AD in other cohorts "rom more recent
ears is even lo3er1 "or e@ample in the lar6e .ational Institute o" Mental /ealth %.IM/&=
"un!e! cohort C.S /I< Antiretroviral 9herap I""ects 5esearch %C/A59I5& it is 2C
L/eaton 51 Manuscript >n!er 5evie3M. /o3ever1 !espite the remar4able e""ect o"
/AA59 on /A.D inci!ence rates1 the prevalence o" /A.D continues to be ver hi6h at
bet3een 1+ an! +0C1 !epen!in6 on the cohort L/eaton 51 Pers. Comm.M1 an! in several
cohorts appears almost [resistantV to the impact o" /AA59. Jor e@ample1 in C/A59I51
+3C o" the total sample ha! neuroco6nitive impairment1 3ith increasin6 rates in those
6roups 3ith 6reater comorbi! illnesses. Prevalence estimates 3ere 33C "or A.I1 12C "or
M.D an! 2C "or /AD L/eaton 51 Pers. Comm.M. In those 3ith inci!ental comorbi!ities1
a histor o" a!vance! /I< !isease %AIDS status an! lo3 na!ir CD,& 3as a stron6er
pre!ictor o" impairment than current !isease status in!icators %current CD,1 plasma an!
CSJ viral loa!s&.
9hus1 neuroco6nitive impairment still presents a si6ni"icant problem "or man /I<=
in"ecte! patients1 an! et clinical 6ui!elines appear to i6nore this issue. Jor e@ample1 the
latest Department o" /ealth an! /uman Services 6ui!elines recommen! initiation o"
/AA59 at an level o" CD, count "or in!ivi!uals 3ith /I<=associate! nephropath1 but
essentiall i6nore /A.D L101M.
A"ter the a!vent o" /AA591 the .IM/ an! the .ational Institute o" .eurolo6ical
Diseases an! Stro4e i!enti"ie! aspects that reFuire! up!atin6. A limitation o" the AA.
criteria 3as that the !i! not reco6niKe a sub6roup o" /I<=in"ecte! patients %R1+C& 3ho
actuall have mil! neuro co6nitive impairment !espite the absence o" overt "unctional
!ecline. 9he there"ore su66este! inclusion o" the term A.I to cate6oriKe in!ivi!uals
3ith subclinical impairment. 9his is characteriKe! b measureable neuroco6nitive
impairment that is not reco6niKe! b the in"ecte! in!ivi!ual %or clinician&1 or "ails to
impact upon "unction. In some sense1 this can be consi!ere! a [presmptomaticV "orm o"
/A.D1 analo6ous to the presmptomatic phases o" AlKheimerVs !isease or /untin6tonVs
!isease. Despite the absence o" smptoms1 in!ivi!uals 3ith A.I ma be more li4el to 6o
on to !evelop the more severe "orms o" /A.D. 9hese ne3 criteria came to be 4no3n as
the Jrascati ratin6 scale an! an al6orithm 3as propose! to assist in stan!ar!iKe!
!ia6nostic classi"ication o" /A.D b this scale.
Accor!in6 to the AA. criteria1 MCMD reFuire! a histor o" impaire!
co6nitive)behavioral "unction in t3o areas %e.6.1 impaire! attention an! concentration1
mental slo3in61 abnormal memor or other co6nitive !s"unctions1 slo3e! movements1
incoor!ination1 personalit chan6e1 irritabilit an! emotional labilit&1 an! these
abnormalities shoul! be associate! 3ith mil! impairment in 3or4 or activities o" !ail
livin6 %AD8s&. 9hose patients 3ho ha! impairments in co6nitive)behavioral "unction but
no impairments in 3or4 or AD8s 3ere classi"ie! as normal. In Jrascati1 the cate6ories
A.I an! M.D 3ere !evelope! speci"i= call to a!!ress this !i""erentiation1 namel the
presence or absence o" impairment in 3or4 or AD8s amon6 patients 3ith mil!
abnormalities on neuropscholo6ical testin6.
In this stu!1 3e compare! a cohort o" patients assi6ne! /A.D ratin6s usin6 the ol!er
AA. an! MS2 ratin6 scale 3ith those o" the ne3er Jrascati ratin6 scale. ?e "oun! that
concor!ance is e@cellent bet3een the ol!er an! ne3 ratin6 scales an! that ,+ MCMD
patients 3ere split almost evenl bet3een A.I %n D 2,& an! M.D %n D 21&. In a!!ition1
ten patients that 3ere consi!ere! normal un!er the ol!er AA. ratin6 scale [shi"te!V into
A.I in the ne3 Jrascati ratin61 hi6hli6htin6 ho3 this ol!er scale ma "ail to !etect earl
si6ns o" neuroco6nitive impairment an! thereb un!er=represent the true prevalence o"
!s"unction.
?hen comparin6 MS2 an! Jrascati ratin6 scales1 3e a6ain note! e@cellent overall
concor!ance. $" note1 M.D cases 3ere all classi"ie! as MS2 0.+. A maAorit o" MS2 0.+
cases "ell into Jrascati A.I ratin61 probabl !ue to lac4 o" an "unctional impairment or
insi6ht re6ar!in6 their impairments.
9hese !iscrepancies point to a possible limitation o" the ne3 Jrascati ratin6 scale1 in that
it relies on the in!ivi!ualVs subAective assessment o" their "unctional status. >n!er=
reportin6 o" "unctional !e"icits can thereb occur 3hen there is poor insi6ht1 an! over=
reportin6 can occur i" the patient is !epresse!. $verall1 ho3ever1 our comparisons sho3
that the Jrascati ran4in6 scale per"orms 3ell an! speci"icall a!!resses the limitations o"
the e@istin6 /A.D ratin6 scales b i!enti"in6 an! more precisel classi"in6
in!ivi!uals 3ith the mil!er sta6es o" /A.D. A limitation o" our stu! 3as that our raters
3ere not blin!e! to the ratin6s o" AA. an! MS2 3hen !eterminin6 the Jrascati ran4.
Althou6h man in!ivi!uals 3ith /A.D remain neurolo6icall stable "or ears a"ter
startin6 /AA591 there are certain in!ivi!uals 3hose co6nitive !ecline continues. In a
stu! that use! M5I assessment1 /I<=in"ecte! patients on A59 still !emonstrate! 6reater
rates o" 3hite matter volume loss than /I<=ne6ative control in!ivi!uals re6ar!less o"
viral loa! L,1+M. >n!erstan!in6 the etiolo6 "or this continue! !ecline is complicate! as
several "actors ma be at pla. Goth !emo6raphic an! me!ical "actors such as a6e1
e!ucational status1 coin"ection 3ith hepatitis C1 as 3ell as severit o" /I< in"ection1 ma
all pla a role in the pro6ression o" the !isor!er.
In the secon! part o" the ana lsis1 3e e@plore! variables associate! 3ith pro6ression o"
/A.D. Most prior stu!ies have "ocuse! on pre!ictors o" /AD rather than pro6ression
throu6h the "ull spectrum o" /A.D1 especiall those per"orme! prior to the 3i!esprea!
use o" /AA59. $l!er stu!ies prior to /AA59 have "oun! /I<=relate! me!ical
smptoms L'M1 lo3er hemo6lobin levels L'M1 hi6her plasma viral loa! L*M1 lo3er CD,
S
cell
counts L1-M an! intravenous !ru6 use L1'M to be associate! 3ith a 6reater ris4 o"
!evelopin6 !ementia. $ther pre=/AA59 stu!ies have "oun! CSJ /I< 5.A levels
associate! 3ith /I< encephalitis L1*M1 co6nitive impairment L20M an! severit o"
!ementia L21(23M. More recent post=/AA59 stu!ies1 3hich also "ocuse! on pre!ictors o"
/AD1 have "oun! con"lictin6 results 3hen loo4in6 at bloo! an! CSJ mar4ers o" immune
activation1 /I< 5.A levels an! CD, counts L2,12+M.
In the secon! part o" the analsis1 3hen e@plorin6 variables associate! 3ith pro6ression
o" /A.D1 3e "oun! that in!ivi!uals 3ho 3ere ol!er than +0 ears o" a6e an! 3omen
3ere more li4el to have neuroco6nitive !ecline. .o other pre!ictors "or the pro6ression
o" /A.D 3ere "oun!1 inclu!in6 sel"=reporte! substance abuse. In "act1 in this population1
men 3ere more li4el to abuse alcohol compare! 3ith 3omen %p D 0.0,-& an! there 3as
no si6ni"icant !i""erence bet3een 6en!ers an! cocaine an! heroin use. $l!er a6e has been
previousl "oun! to increase the ris4 o" !evelopin6 /AD L2B(2*M. In the pre=/AA59 era1
t3o stu!ies reporte! that 3omen have more rapi! pro6ression o" neurolo6ical si6ns an!
smptoms L'130M. In the post=/AA59 era1 "emale 6en!er as a pre!ictor "or pro6ression o"
/A.D has not been previousl reporte!. 9his ma be in part o3in6 to a "in!in6 that
3omen 3ith /A.D have !ecrease! "unction an! activit o" antio@i!ant enKmes in CSJ
an! monoctes1 thus possibl resultin6 in more o@i!ative stress in the C.S an! thereb
promotin6 pero@nitrite "ormation an! neuronal !ama6e L31132M. $n "urther analsis o"
this subset1 3e !i! "in! that 3omen ha! si6ni"icantl "e3er ears o" e!ucation compare!
3ith men1 3hich ma e@plain their 3orsenin6 /A.D status. 8o3er e!ucation is
associate! 3ith more variabilit on repeat neuroco6nitive assessments1 an! it is possible
that the chan6e in /A.D status re"lects ran!om test(retest variabilit rather than a true
biolo6ical chan6e. 8ess e!ucation ma also result in less co6nitive reserve1 3hich is the
e""icient utiliKation o" brain net3or4s or o" enhance! abilit to recruit alternate brain
net3or4s to cope 3ith or compensate "or patholo6 L33M. 9here"ore1 althou6h this "in!in6
is potentiall interestin61 it nee!s to be vali!ate! b lar6er stu!ies. $" note1 most o" our
subAects 3ere ta4in6 /AA59 an! their clinical !isease 3as 3ell controlle!; as Au!6e! b
plasma /I< 5.A control1 appro@imatel +-C 3ere un!etectable. $n /AA591 /A.D is
4no3n to be usuall stable an! the maAorit o" in!ivi!uals 3ith /A.D !o not pro6ress
on /AA59 but instea! sho3 "reFuent bi!irectional transitions. ?e ha! 1, subAects %31C&
3ho pro6resse! in their /A.D ran4in6 usin6 the Jrascati scale in the 12=month perio!.
/o3ever1 i" 3e ha! use! the ol!er AA. scale "or our assessment1 three o" these 1, 3oul!
have been consi!ere! stable as pro6ression 3as "rom A.I to M.D. 9hus1 the Jrascati
scale ma be more sensitive to neurolo6ical pro6ression !ue to the more precise
!elineation in this mil!er sta6e o" this !isease.
9his stu! sho3s that the Jrascati !ementia ratin6 scale has 6oo! concor!ance 3ith the
MS2 an! AA. ratin6 scale an! can be use! to more precisel !escribe the !isor!er1
particularl in mil!er sta6es o" co6nitive impairment. Pro6ression o" /A.D in this stu!
3as more li4el in subAects ol!er than +0 ears an! 3omen1 an! the proportion sho3in6
pro6ression 3as surprisin6l hi6h1 even thou6h the overall stu! numbers 3ere small. In
the post=/AA59 era o" /I<1 pro6ression o" /A.D is thou6ht to be less li4el but lar6er
stu!ies are nee!e! to evaluate those "actors that mi6ht allo3 "or the more accurate
pre!iction o" chan6e in neuroco6nitive status ratin6s an! thus vali!ate our "in!in6s.
&/ecuti-e summary
Introduction
9ri6inal scales used to dia6nose HIV<associated neuroco6nitive
disorders %HA-,' =ere the Memorial .loan >etterin6 %M.>' scale and
the American Academ# o! -eurolo6# %AA-' scale.
In 200(1 revised classication =as proposed in ;rascati1 Ital#1 to
represent the presentation o! neuroco6nitive disturbances in the post<
HAA3T era1 characteri?ed b# milder !orms o! neuroco6nitive
disturbance.
More precise criteria !or three s#ndromes =ithin the !rame=or7 o!
HA-, =as established" as#mptomatic neuroco6nitive impairment
%A-I'; mild neuroco6nitive disorder %M-,'; and HIV<associated
dementia %HA,'.
Althou6h most individuals =ith HA-, remain neurolo6icall# stable a!ter
startin6 HAA3T1 there is a subset o! individuals =hose neuroco6nitive
!unction continues to decline.
The current stud# =as desi6ned to e4amine the concordance bet=een
the ;rascati scale and the t=o older scales and to evaluate the
predictive in@uence o! baseline sociodemo6raphic and clinical
characteristics on pro6ression o! HA-, usin6 this ne=er scale.
%ethods
A total o!10$ HIV<in!ected individuals ever# A)12 months completed
the !ollo=in6" standardi?ed Buestionnaires to capture demo6raphics
and medical1 ps#chiatric and neurolo6ical histor#; clinical e4amination;
depression assessment; and laborator# assessment.
,ia6nosis o! HA-, made usin6 the AA-1 M.> and ;rascati
classication.
-europs#cholo6ical testin6 and !unctional assessment per!ormed at
each visit.
Concordance bet=een M.> ratin6 scales carried out usin6 the
0oodman<>rus7al C statistic.
A subset o! $/ HIV<in!ected individuals assessed at 1 #ear !ollo=in6
baseline !or chan6e in ;rascati ratin6.
Associations bet=een sociodemo6raphic characteristics measured at
baseline %a6e D /0 #ears1 race1 colle6e education1 6ender1 clinical
depression per Eec7 ,epression Inventor#1 substance abuse histor#1
hepatitis C status and C,$
F
count less than 200 cells+mm
&
' and chan6e
in co6nitive status %improved1 stable or =orse' e4amined usin6 lo6istic
re6ression.
"esults
Concordance bet=een the ;rascati and the M.> and AA- scales =as
e4cellent %0oodman<>rus7al C G 0.H'
Cases that =ere rated as minor co6nitive motor disorder on the AA-
scale =ere split bet=een A-I and M-, on the ;rascati scale.
Ten individuals considered normal under the AA- ratin6 scale !ell
=ithin the A-I cate6or# in the ;rascati scale.
9! the $/ patients !ollo=ed<up a!ter 1 #ear1 &1I sho=ed declines in
neuroco6nitive !unction1 /AI =ere stable and 1&I sho=ed
improvement.
Individuals older than /0 #ears and =omen =ere more li7el# to
demonstrate neuroco6nitive decline.
Jomen1 ho=ever1 had si6nicantl# !e=er #ears o! education compared
=ith men.
Discussion
A!ter the introduction o! HAA3T in 1**A1 the incidence o! HA, has
declined.
The prevalence o! HA, is estimated at 2I; the prevalence o! less
severe !orms o! HA-, is hi6h1 bet=een 1/ and /0I.
The inclusion o! the term as#mptomatic neuroco6nitive impairment to
cate6ori?e individuals =ith subclinical impairment and mild
neuroco6nitive disorder =as added to ne= criteria 7no=n as the
;rascati ratin6 scale.
The cate6ories A-I and M-, =ere developed specicall# to address
the presence or absence o! impairment in =or7 or activities o! dail#
livin6 amon6 patients =ith mild abnormalities on neurops#cholo6ical
testin6.
Prevalence estimates are &&I !or A-I and 12I !or M-,.
Concordance is e4cellent bet=een the older and ne= ratin6 scales.
The cate6or# A-I helps detect earl# si6ns o! neuroco6nitive
impairment that =ere missed =ith the older ratin6 scales.
The ;rascati scale addresses limitations o! the older scales b#
identi!#in6 and more precisel# classi!#in6 individuals =ith milder
sta6es o! HA-,.
Althou6h man# individuals =ith HA-, remain neurolo6icall# stable !or
#ears a!ter startin6 HAA3T1 in certain individuals co6nitive decline
continues.
HIV<in!ected patients on A3T still demonstrated 6reater rates o! =hite
matter volume loss.
In this stud#1 variables associated =ith pro6ression o! HA-, =ere a6e
6reater than /0 #ears and !emale 6ender.
-o other predictors !or the pro6ression o! HA-, =ere !ound1 includin6
sel!<reported substance abuse.
In the post<HAA3T era1 !emale 6ender as a predictor !or pro6ression o!
HA-, has not been previousl# reported.
Ho=ever1 =omen had si6nicantl# !e=er #ears o! education1 =hich
ma# e4plain their =orsenin6 HA-, status.
Je had &1I =ho pro6ressed in their HA-, ran7in6 usin6 the ;rascati
scale. Ksin6 the older AA- scale1 three out o! 1$ =ould have been
considered stable as pro6ression =as !rom A-I to M-,1 resultin6 in
onl# 2$I pro6ression.
Thus1 the ;rascati scale is more sensitive to neurolo6ical pro6ression
due to the more precise delineation in this milder sta6e o! disease.
0o to"
,ootnotes
&thical conduct of research
9he authors state that the have obtaine! appropriate institutional revie3 boar! approval
or have "ollo3e! the principles outline! in the Declaration o" /elsin4i "or all human or
animal e@perimental investi6ations. In a!!ition1 "or investi 6ations involvin6 human
subAects1 in"orme! consent has been obtaine! "rom the participants involve!.
,inancial 0 competin' interests disclosure
9he authors 3ere supporte! b the Johns /op4ins .IM/ Center "or .ovel 9herapeutics
in /I< Associate! Co6nitive Disor!er %M/ 0-+B-3&1 %M/-11+0& an! %.S 0,*,B+&. 9he
authors have no other relevant a""iliations or "inancial involvement 3ith an or6aniKation
or entit 3ith a "inancial interest in or "inancial con"lict 3ith the subAect matter or
materials !iscusse! in the manuscript apart "rom those !isclose!.
.o 3ritin6 assistance 3as utiliKe! in the pro!uction o" this manuscript.
0o to"
+iblio'raphy
Papers o" special note have been hi6hli6hte! as#
o" interest
o" consi!erable interest
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Jurnal %
3esearch article
Do common mental disorders decline o-er
time in !+1HIV co-infected and HIV
patients without !+ who are on
antiretro-iral treatment2
Amare Deribew
1T
1 Kebede Deribe
2
1 Ayalu A "eda
3
1 %ar3os !esfaye
,
1 4ohannes
Hailmichael
+
an! !odd %a5a
B

T Correspon!in6 author# Amare Deribe3 amare_!eribe3`ahoo.com
Author A""iliations
1
Department o" Ipi!emiolo61 Jimma >niversit1 Jimma1 Ithiopia
2
Gri6hton an! Susse@ Me!ical School1 Jalmer1 Gri6hton1 >2
3
Colle6e o" Public /ealth1 /aromaa >niversit1 /arar1 Ithiopia
,
Department o" Pschiatr1 Jimma >niversit1 Jimma1 Ithiopia
+
Department o" /ealth Service Mana6ement1 Jimma >niversit1 Jimma1 Ithiopia
B
Department o" /ealth Stu!ies1 >.ISA1 P$ Go@ 3*21 Pretoria1 South A"rica
Jor all author emails1 please lo6 on.
BMC Psychiatry 20131 67#1-, !oi#10.11'B)1,-1=2,,W=13=1-,
9he electronic version o" this article is the complete one an! can be "oun! online at#
http#))333.biome!central.com)1,-1=2,,W)13)1-,
3eceived"
2( 5ul#
2012
Accepted"
2/ 5une
201&
Published"
2( 5une
201&
a 2013 Deribe3 et al.; licensee GioMe! Central 8t!.
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Abstract
+ac3'round
9he relationship bet3een 9G)/I< co=in"ection an! common mental !isor!ers %CMD& is
not 3ell investi6ate!. A "ollo3 up stu! 3as con!ucte! to assess the chan6e in CMD over
a B=months perio! an! its pre!ictors amon6 9G)/I< co=in"ecte! an! /I< patients
3ithout 9G in Ithiopia.
%ethods
A lon6itu!inal stu! 3as con!ucte! in 200*. A total o" ,B+ /I<)AIDS patients 3ithout
9G an! 12, 9G)/I< co=in"ecte! patients "rom "our antiretroviral treatment %A59& centers
in Ithiopia 3ere recruite! to assess CMD an! Fualit o" li"e %Eo8&. CMD an! Eo8 3ere
assesse! at baseline an! at si@ month usin6 the 2essler=10 scale an! the short Amharic
version o" the ?orl! /ealth $r6aniKation Eualit o" 8i"e Instrument "or /I< clients
%?/$E$8 /I<=Gre"& respectivel. Multivariate analsis 3as con!ucte! usin6
6eneraliKe! estimatin6 eFuations %;II& usin6 S9A9A to assess chan6e in CMD an! its
pre!ictors.
"esults
At the B month1 +,0 %*- 9G)/I< co=in"ecte! an! ,++ /I<)AIDS patients 3ithout 9G&
patients complete! the "ollo3 up an! '.BC %21C amon6 9G)/I< co=in"ecte! an! 2.2C
amon6 /I< patients 3ithout 9G& lost to "ollo3=up.
At baseline1 +,.,C o" 9G)/I< co=in"ecte! patients ha! mil! to severe mental !isor!er
compare! to ,1.2C amon6 /I< patients 3ithout 9G. At the si@ month "ollo3 up1 1'.1C
o" 9G)/I< co=in"ecte! patients ha! mil! to severe mental !isor!er compare! to 21.'C
amon6 /I< patients 3ithout 9G. 9he !ecline o" the prevalence o" an "orm o" metal
!isor!er 3as 3B.3C amon6 9G)/I< co=in"ecte! patients compare! to 1*.,C amon6 /I<
patients 3ithout 9G %PR0.001&.
Eo8 3as stron6l associate! 3ith CMD in 9G)/I< co=in"ecte! patients an! /I< patients
3ithout 9G %b D ^0.0,1 PR0.001& a"ter controllin6 the e""ect o" several con"oun!in6
variables such as se@1 income1 ?/$ !isease sta6e1 !uration on A591 CD, lmphocte
count1 a!herence to A59 an! social support.
Conclusion
9he prevalence o" CMD has si6ni"icantl re!uce! particularl amon6 9G)/I< co=
in"ecte! patients over a B months perio!. Poor Eo8 is the maAor in!epen!ent pre!ictors o"
CMD. ?e recommen! inte6ration o" mental health services in 9G)/I< pro6rams.
9rainin6 o" health care provi!ers at 9G)/I< clinics coul! help to screen an! treat CMD
amon6 9G)/I< co=in"ecte! patients.
Keywords:
TE+HIV Co<in!ection; Wualit# o! 8i!e; Common Mental ,isorders; Nthiopia
+ac3'round
.europschiatric con!itions represent 13C o" the total !isease bur!en an! it is the thir!
lar6est cause o" !isabilit=a!Auste! li"e ears lost %DA80s& a"ter in"ectious an! parasitic
!iseases %,1C& an! car!iovascular !iseases %2BC& L1M.
9he importance o" mental health is estimate! to increase in the ne@t t3o !eca!es. Mental
health con!itions such as !epression are proAecte! to become the lea!in6 bur!en o"
DA80s b the ear 2030 L213M. 9hree=Fuarters o" this bur!en occurs in the !evelopin6
3orl! 3here 9uberculosis an! /I< are prevalent L213M.
9uberculosis %9G& an! /I< co=in"ection comprises an enormous bur!en on in!ivi!uals
an! health care sstems particularl in resource constraine! countries L,1+M. 5ecentl1 co=
morbi!ities bet3een mental health an! in"ectious !iseases an! inte6ration o" these
!iseases in the primar health care are 6ettin6 much attention. Je3 stu!ies have
!ocumente! the interaction bet3een /I<)AIDS an! mental health problems. 9he
presence o" mental !isor!er1 particularl !epression1 pre!isposes in!ivi!uals to
unprotecte! se@ual behavioral an! !ru6 abuse 3hich are the maAor ris4 "actors "or
/I<)AIDS in"ection LBM. $n the other han!1 /I<)AIDS in"ection causes pscholo6ical
trauma an! a""ect the nervous sstem !irectl resultin6 in !epression1 mania an! other
co6nitive !isor!ers L-=11M. $pportunistic in"ections as a result o" /I<)AIDS LBM an! anti=
retroviral !ru6s particularl e"avirenK can also cause mental health !isor!ers LBM.
Je3 stu!ies have !ocumente! hi6h prevalence o" tuberculosis amon6 in!ivi!uals 3ith
mental health problems L12113M. In a!!ition1 hi6h prevalence o" !epression 3as recor!e!
amon6 tuberculosis patients compare! to health controls L1,11+M.
9he comple@ interaction amon6 9G1 /I< an! mental !isor!ers coul! a""ect the Fualit o"
li"e %Eo8& o" in!ivi!uals L,11B11-M. Since the a!vent o" A591 the inci!ence o" /I<=
associate! !ementia has halve! L1'M an! the prevalence o" opportunistic in"ection o" the
central nervous sstem !ecrease! L1'11*M. /o3ever1 there are reports in!icatin6 rise in
the inci!ence o" /I< encephalopath L1*M.
9here is a !earth o" literature on the mental health status o" 9G)/I< co=in"ecte! patients
over time. ?e con!ucte! a "ollo3 up stu! in Ithiopia to !ocument the chan6es in
prevalence o" CMD an! its pre!ictors amon6 9G)/I<=co=in"ecte! an! /I< patients
3ithout 9G over si@ months perio!.
%ethods
Study settin's and population
9his is a lon6itu!inal stu! 3ith B month "ollo3=up perio!. 9he baseline surve 3as
con!ucte! "rom Jebruar to April1 200* to assess the prevalence o" CMD amon6 ,B+
/I<)AIDS patients 3ithout 9G an! 12, 9G)/I< co=in"ecte! patients "rom the A59
clinics o" A!ama1 .e4emet an! Jimma specialiKe! hospitals in Ithiopia. 9he
metho!olo6 an! the baseline "in!in6s are publishe! in a previous article L1BM. In 6eneral1
,B+ patients 3ithout 9G an! 12, 9G)/I< co=in"ecte! patients 3ho 3ere ta4in6 A59 3ere
recruite! in the three hospitals to compare CMD amon6 the t3o 6roups. 9he sample siKe
3as !etermine! base! on the "ollo3in6 assumptions# +C lo3er mean score o" phsical
Eo8 li"e amon6 9G)/I< co=in"ecte! patients compare! to /I< patients 3ithout 9G1
*+CCI1 a 1#3 ratio o" /I<)9G co=in"ecte! patients versus /I< patients1 an! a 10C "or
non=response rate. All the 9G)/I< co=in"ecte! patients 3ere in the intensive phase o"
anti=9G treatment !urin6 the recruitment perio!. Jor each 9G)/I< co=in"ecte! patients1 3
/I< patients 3ithout active 9G 3ere selecte! in the 9G)/I< clinics usin6 a simple
ran!om samplin6 techniFue. 9he e@clusion criteria "or both 6roups 3ere a6e less than 1+
ears1 the presence o" an opportunistic in"ection or a 4no3n chronic illness li4e !iabetes
mellitus an! hpertension.
Data collection procedures and follow up
Dia6noses o" 9G an! /I< at baseline 3ere base! on the national 6ui!eline L20M. Smear
microscop 3as the maAor !ia6nostic tool "or pulmonar 9G. 9G lmpha!enitis 3as
!ia6nose! base! on clinical parameters an! ctolo6ical e@amination obtaine! b "ine
nee!le aspiration. 9G 3as e@clu!e! "rom the /I< patients b a thorou6h smptom
screenin6.
A"ter recruitment1 patients 3ere appointe! monthl to the A59 clinics o" the respective
hospitals to ta4e their me!ication %anti=retroviral an! ant=9G !ru6s&. Durin6 each visit1
patients 3ere thorou6hl assesse! b traine! nurses "or !ru6 si!e e""ects1 6eneral health
status an! presence o" smptoms o" opportunistic in"ection inclu!in6 9G. CD,
lmphocte count an! ?/$ clinical sta6in6 3ere e@tracte! "rom the patientsV recor! at
baseline an! at the B
th
month. CMD an! Eo8 3ere measure! at baseline an! at the B
th

month o" "ollo3 up.
Common Mental Disor!er 3as measure! usin6 the 2essler 10 scales L21M. 9he 2essler=10
scales is vali!ate! in Ithiopia a6ainst pschiatristsV !ia6nosis usin6 the comprehensive
pschopatholo6ical scale L22123M an! it contains 10 Fuestions each containin6 +=point
8i4ert scales %1 D never1 2 D a small part o" the time1 3 D some o" the time1 , D most o"
the times1 + D all o" the time&. 9he 2=10 instrument is a use"ul screenin6 tool to i!enti"
CMD such as !epression1 an@iet an! somato"orm !isor!ers. It as4s Fuestions re6ar!in6
the presence o" !epression1 tire!ness1 nervousness1 restlessness1 hopelessness1 an!
3orthlessness in 30 !as prior to the surve. 9o assess the !e6ree o" mental health status
o" in!ivi!uals1 CMD 3as cate6oriKe! as normal %score R20&1 mo!erate %score 20=2,&1 an!
severe %score above 2+& base! on the recommen!ations o" other authors L21123M. Several
stu!ies have use! cut o"" score 20 to i!enti" cases CMD L2,12+M.
Eo8 3as measure! throu6h "ace to "ace intervie3 usin6 the short Amharic version o" the
?orl! /ealth $r6aniKation Eualit o" 8i"e Instrument "or /I< clients %?/$E$8 /I<=
Gre"& L2BM. 9he Eo8 instrument is publishe! in the previous article L1BM. In brie"1 it
consiste! o" 31 8i4ert scale Fuestions in si@ !omains o" Eo8# Phsical health %, items&;
pscholo6ical 3ell bein6 %+ items&; social relationship %, items&; environmental health %'
items&; level o" in!epen!ence %, items& an! spiritual health %, items&. 9here 3ere t3o
6eneral Fuestions about 6eneral Eo8 an! perceive! 6eneral health. 9he overall Fualit o"
li"e 3as measure! usin6 all the Fuestions as !escribe! in else3here L2BM.
Data analysis
Data 3ere analKe! usin6 the SPSS version 1B.0 an! S9A9Ac version 11 so"t3are. Items
score o" the 2=10 3ere summe! to create a continuous CMD outcome variable. Similarl1
items scores o" the ?/$E$8=/I<=Gre" instrument 3as summe! to create a continuous
Eo8 e@posure variable. ?e use! t=test an! J=test to compare means o" CMD bet3een
6roups.
Paire!=9=tests 3ere use! to compare repeate! measurements o" CMD at baseline an! si@
months. Multivariate analsis 3as con!ucte! usin6 6eneraliKe! estimatin6 eFuations
%;II& usin6 the ;aussian "amil an! the i!entit lin4 "unction. In this mo!el1 the
correlations bet3een the baseline an! B=month measurements are ta4en into account.
<ariables 3ith si6ni"icant correlation 3ere remove!. A P=value o" less or eFual to 0.0+
3as ta4en as the cut=o"" value "or si6ni"icance.
&thical considerations
Ithical clearance 3as obtaine! "rom the Jimma >niversit ethical revie3 boar!. ?ritten
in"orme! consent 3as obtaine! "rom the stu! participants. 9o ensure con"i!entialit1 3e
use! co!es to analKe the !ata. Patients 3ho score! above 20 on the 2essler scale 3ere
re"erre! to Pschiatr units in each hospital "or "urther !ia6nosis an! mana6ement.
"esults
At baseline1 ,B+ /I< patients 3ithout 9G an! 12, 9G)/I< co=in"ecte! patients 3ere
inclu!e!. $" the co=in"ecte! patients1 smear ne6ative1 smear positive an! e@tra pulmonar
9G accounte! "or B1 %,*.2C&1 ,2 %33.*C&1 21 %1B.*C& respectivel. At B month1 +,0 %*-
9G)/I< co in"ecte! an! ,++ /I< patients 3ithout 9G& patients complete! the "ollo3 up
an! '.BC lost to "ollo3=up. $ver the si@ months perio!1 +),,3%1.12C& /I<)AIDS
patients !evelope! active pulmonar 9G. Durin6 the "ollo3 up perio!1 -.1C o" the
9G)/I< co=in"ecte! patient !iscontinue! their anti=9G treatment at least once an! 10
%1.'C& patients 3ith /I<)AIDS misse! at least one !ose o" A59 %9able 1&.
!able 68 Socio-demo'raphic characteristics of participants at 9 months of follow up
Common mental disorders at baseline and 9-months
At baseline1 2,.'C an! 1+.2C o" the 9G)/I< co=in"ecte! patients ha! severe an!
mo!erate "orm o" CMD respectivel. $n the other han!1 the prevalence o" severe "orm o"
CMD amon6 /I<)AIDS patients 3ithout 9G at baseline an! B month 3as '.BC an! 3.'C
respectivel. At the si@ month1 the prevalence o" severe "orm o" CMD amon6 9G)/I<=co=
in"ecte! patients 3as 1.*C 3hich sho3e! a !i""erence o" 22.* percenta6e=points. An
"orm o" mental !isor!er ha! !ecrease! b 3B.3 percenta6e points in 9G)/I< co=in"ecte!
patients at si@ month compare! to the baseline. An "orm o" CMD amon6 /I<)AIDS
patients 3ithout 9G 3as re!uce! b 1*., percenta6e points at the si@ month %9able 2&.
!able :8 Chan'e in common mental disorders o-er 9 months follow-up amon'
participants
Predictors of common mental disorders
Eo8 3as stron6l associate! 3ith CMD in 9G)/I< co=in"ecte! patients an! /I<)AIDS
patients 3ithout 9G %b D ^0.0,1 PR0.001& a"ter controllin6 the e""ect o" several
con"oun!in6 variables such as se@1 income1 CD, lmphocte count1 a!herence to A59
an! social support %9able 3&.
!able 78 Predictors of C%D amon' !+1HIV co-infected and HIV1AIDS patients
without !+; &thiopia
A 5$C curve e@plorin6 the best cut=o"" points o" phsical an! pscholo6ical Fualit o"
li"e as pre!ictors o" CMD sho3e! that Eo8 is the best pre!ictors o" CMD 3ith area un!er
the curve o" 0.'2. A cut o"" point o" 11.+ "or phsical an! 1,.0 "or pscholo6ical
!imension o" Eo8 6ave '0C sensitivit %Ji6ure 1&.
,i'ure 68 "#C cur-e e/plorin' .o( chan'e of cut off point for
predictin' C%D amon' !+1HIV co-infected and HIV patients without !+; &thiopia
<area under the cur-e= physical>?8@6@ and psycholo'ical .o(>?8@:6= both areas are
statistically si'nificantly from an areas of ?8AB8
Discussion
9his is the "irst "ollo3 up stu! to evaluate the chan6e in CMD amon6 9G)/I< co=
in"ecte! an! /I< patients 3ithout 9G 3ho are on A59 in Ithiopia. 9his stu! reveals
that there is si6ni"icant !ecline in the prevalence o" CMD particularl amon6 9G)/I< co=
in"ecte! patients over a si@ month perio!. 9he chan6e in CMD prevalence amon6
9G)/I< co=in"ecte! in!ivi!uals is t3ice than that o" /I< patients 3ithout 9G. Amon6
several e@posure variables1 Eo8 is the best pre!ictors o" CMD both in co=in"ecte!
patients an! /I<)AIDS patients 3ithout 9G.
9his stu! reveals that the prevalence o" CMD amon6 9G)/I< co=in"ecte! an! /I<
patients 3ithout 9G is ver hi6h. $ther literatures have also !ocumente! hi6h prevalence
o" mental health problems amon6 people 3ith /I<)AIDS L'1*M an! patients 3ith
tuberculosis L12113M. In the present stu!1 the !ecline in prevalence o" CMD at the B
month o" treatment an! "ollo3 up 3as more mar4e! amon6 9G)/I< patients compare to
people livin6 3ith /I< 3ithout 9G. 9his coul! be e@plaine! b t3o maAor reasons. Jirst1
in the continuation phase o" anti=9G treatment %2=' months&1 the phsical an! "unctional
status o" the patients coul! improve si6ni"icantl 3hich in turn brin6s improve! mental
health status o" in!ivi!uals. Secon!1 perceive! sti6ma associate! 3ith 9G mi6ht also be
re!uce! at B months o" anti=9G treatment. 5e!uction in sti6ma mi6ht have maAor e""ect
on the mental status o" patients. Previous stu! has proven that presence o" perceive!
sti6ma is hi6hl associate! 3ith !epression L1B12-M. A stu! in >6an!a has also reveals
that Fualit o" li"e an! mental health status has improve! at 12=monhts o" A59 L2'M. In
our stu!1 continues counselin6 an! health e!ucation 6iven b the health care provi!ers
about a!herence1 !iets1 an! sel"=care an! prevention o" opportunistic in"ections mi6ht
contribute "or the re!uction o" CMD in both 6roup o" patients.
In our stu!1 Eo8 3as the best pre!ictor o" CMD; ho3ever1 CMD coul! also cause
poorer Eo8 amon6 patients 3ith 9G)/I< !isease. In this stu!1 3e coul! not establish the
temporal relationship o" the t3o con!itions. 8iteratures on the relationship bet3een Eo8
an! mental !isor!ers are lac4in6 3orl!3i!e. A 3ell !esi6ne! cohort or clinical trial coul!
be help"ul to establish the temporal relationship bet3een mental !isor!ers an! Eo8.
Despite si6ni"icant re!uction in CMD at the B=months o" "ollo3 up1 CMD is still a maAor
co=morbi!it o" 9G)/I< !isease. In a countr such as Ithiopia 3here mental health is not
an inte6ral part o" /I<)AIDS or 9G care an! treatment services1 CMD 3oul! have
ne6ative impact on the treatment outcome o" patients LBM. Mental !isor!ers such as
!epression mi6ht also have ne6ative impact on immune status o" patients 3hich
counteract the bene"it o" A59 LBM.
(imitations of the study
9his stu! is the "irst o" its 4in! to evaluate the tren!s in CMD amon6 9G)/I< co=
in"ecte! patients. 9he sample siKe is a!eFuate to measure the chan6e an! the e""ect siKe.
/o3ever1 the "ollo3 up perio! is too short to analKe multiple con"oun!ers usin6 survival
analsis an! Co@ re6ression. 8oss to "ollo3 up o" more 9G)/I< co=in"ecte! patients
compare! to /I<)AIDS patients 3ithout 9G coul! also intro!uce! bias. /o3ever1 the
loss to "ollo3 up 6roup is not si6ni"icantl !i""erent "rom the other 6roup e@cept in the
?/$ clinical sta6e. Most o" the lost to "ollo3=up 3ere in ?/$ sta6e 3 an! , %PD0.002&.
Conclusions and recommendations
9he prevalence o" CMD has si6ni"icantl re!uce! particularl amon6 9G)/I< co=
in"ecte! patients over a B months perio!. /o3ever1 CMD is still a maAor co=morbi!it o"
9G)/I< !isease. Poor Eo8 is the maAor in!epen!ent pre!ictors o" CMD.
Gase! on the "in!in6s o" this stu!1 3e recommen! the inte6ration o" mental health
services in 9G)/I< pro6rams. 9rainin6 o" health care provi!ers at 9G)/I< clinics coul!
be help"ul to screen an! treat CMD amon6 9G)/I< co=in"ecte! patients.
Competin' interests
9he authors !eclare that the have no "inancial or non="inancial competin6 interests.
AuthorsC contributions
AD conceive! the stu! an! 3as involve! in the !esi6n1 analsis an! report 3ritin6. 2D
3as involve! in analsis an! !ra"te! the manuscript. AA5 analKe! the !ata an!
revie3e! the article. M9 participate! in the !esi6n an! revie3e! the article. 0/
participate! in the !esi6n an! criticall revie3e! the article. 9M has revie3e! the article
e@tensivel. All authors rea! an! approve! the "inal manuscript.
Ac3nowled'ements
9he authors ac4no3le!6e the /I< prevention an! control o""ice o" the $romia re6ional
health Gureau "or "un!in6 the stu!. 9he authors appreciate the stu! participants "or
their cooperation in provi!in6 the necessar in"ormation. 2D is supporte! b a ?ellcome
9rust research trainin6 "ello3ship %0**'-B&.
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Health !ual Life "utcomes 20121 6?%1&:--. PubMe! Abstract d
GioMe! Central Jull 9e@t d PubMe! Central Jull 9e@t
1'. Sac4tor .1 8les 5/1 S4olas4 5# HIV-associated neurolo'ic disease incidence
chan'es: %ulticenter AIDS Cohort Study; 6HH?-6HH@8
*eurology 20011 A9:2+-=2B0.
Cross5e" d PubMe!
PubMed Abstract X Publisher ;ull Te4t
1*. .euenbur6 J21 Gro!t /51 /ern!ier G;# HIV-related neuropatholo'y; 6H@A to
6HHH: risin' pre-alence of HIV encephalopathy in the era of hi'hly acti-e
antiretro-iral therapy8
' (c,uir )mmune Defic Syndr 20021 76:1-1=1--.
Cross5e" d PubMe!
PubMed Abstract X Publisher ;ull Te4t
20. Je!eral Ministr o" /ealth Ithiopia# Guideline for the national #B Leprosy
Control Programme in Ethiopia. A!!is Ababa# M$/; 200-.
21. 2essler 5C1 An!re3s ;1 Colpe 8J1 /iripi I1 MrocKe4 D21 .orman! S81 ?alters
II1 Xaslavs4 AM# Short screenin' scales to monitor population pre-alence
and trends in non-specific psycholo'ical distress8
Psychol Med 20021 7::*+*=*-B. PubMe! Abstract d Publisher Jull 9e@t
22. 9es"ae M1 /anlon C1 ?on!ima6e6n D1 Alem A# Detectin' postnatal common
mental disorders in Addis Ababa; &thiopia: -alidation of the &dinbur'h
Postnatal Depression Scale and Kessler Scales8
' (ffect Disord 20101 6::%1(2&:102=10'. PubMe! Abstract d Publisher Jull 9e@t
23. An!re3s ;1 Sla!e 9# Interpretin' scores on the Kessler Psycholo'ical Distress
Scale <36?B8
(ust * - ' Public Health 20011 :A:,*,=,*-. PubMe! Abstract d
Publisher Jull 9e@t
2,. Don4er 91 ComiAs /1 CuiApers P1 9erluin G1 .olen ?1 Xitman J1 Pennin@ G# !he
-alidity of the Dutch K6? and e/tended K6? screenin' scales for depressi-e
and an/iety disorders8
Psychiatry +es 20101 6E9%1&:,+=+0. PubMe! Abstract d Publisher Jull 9e@t
2+. Juru4a3a 9A1 2essler 5C1 Sla!e 91 An!re3s ;# !he performance of the K9
and K6? screenin' scales for psycholo'ical distress in the Australian ational
Sur-ey of %ental Health and )ell-+ein'8
Psychol Med 20031 77:3+-=3B2. PubMe! Abstract d Publisher Jull 9e@t
2B. $VConnel 21 S4evin6ton S1 Sa@ena S# Preliminary de-elopment of the )orld
Health #r'aniFationCs .uality of (ife HIV instrument <)H#.#(-HIVB:
analysis of the pilot -ersion8
Soc Sci Med 20031 AE:12+*=12-+. PubMe! Abstract d Publisher Jull 9e@t
2-. Perlic4 DA1 5osenhec4 5A1 Clar4in JJ1 Sire JA1 Salahi J1 Struenin6 I81 8in4
G;# Sti'ma as a barrier to reco-ery: Ad-erse effects of percei-ed sti'ma on
social adaptation of persons dia'nosed with bipolar affecti-e disorder8
Psychiatr Ser 20011 A:%12&:1B2-=1B32. PubMe! Abstract d Publisher Jull 9e@t
2'. Stan6l A81 ?amai .1 Mermin J1 A3or AC1 Gunnell 5I# !rends and predictors
of Duality of life amon' HIV-infected adults ta3in' hi'hly acti-e
antiretro-iral therapy in rural $'anda8
()DS Care 200-1 6H%+&:B2B=B3B. PubMe! Abstract d Publisher Jull 9e@t
Jurnal &
Ann 0en Ps#chiatr#. 201&; 12" 1H.
Published online 201& 5une 11. doi" 10.11HA+1($$<H/*S<12<1H
PMCI," PMC&AH2H(2
%ental health; childhood abuse and HIV
se/ual ris3 beha-iour amon' uni-ersity
students in I-ory Coast
>arl Pelt?er1
1121&
.upa Pen6pid1
21&
and Issa7a Tiembre
$
Author in!ormation : Article notes : Cop#ri6ht and 8icense in!ormation :
0o to"
Abstract
+ac3'round
8ittle "ocus has been pai! to the role o" poor mental health an! chil!hoo! abuse amon6
oun6 people 3ith re6ar! to human immuno!e"icienc virus %/I<& ris4 behaviour an!
/I< prevention in A"rica. 9he aim o" this stu! 3as to !etermine the association bet3een
mental health1 chil!hoo! abuse an! /I< se@ual ris4 behaviour amon6 a sample o"
universit stu!ents in Ivor Coast.
%ethods
A cross=sectional surve 3as con!ucte! 3ith un!er6ra!uate stu!ents that 3ere recruite!
ran!oml "rom classes at the Jeli@ /ouphouft Goi6n >niversit o" Coco!. 9he sample
inclu!e! '2, universit stu!ents %+0C men an! +0C 3omen&1 3ith a mean a6e o" 23.-
ears %SD D 2.-&.
"esults
$" the '2, universit stu!ents 3ho complete! the surve1 1-.BC reporte! !epression1
10.'C screene! positive "or post=traumatic stress !isor!er1 '.3C reporte! at least monthl
heav episo!ic !rin4in61 13.+C reporte! chil!hoo! phsical abuse an! ,.-C se@ual
abuse1 33.*C ha! t3o or more se@ual partners in the past 12 months1 BB.3C ha!
inconsistent con!om use1 23.BC ha! alcohol use in the conte@t o" se@ an! 1B.-C ha! a
histor o" a se@uall transmitte! in"ection In multivariable analsis amon6 men1 lac4 o"
reli6iousness an! alcohol use in the conte@t o" se@ 3ere associate! 3ith /I< ris4
behaviour1 an! amon6 3omen1 poorer "amil bac46roun!1 e@perience o" se@ual an!
phsical partner violence1 alcohol use in the conte@t o" se@ an! !epression 3ere
associate! 3ith /I< ris4 behaviour.
Conclusions
Poor mental health %!epression& inclu!in6 alcohol use an! partner violence 3as "oun! to
be associate! 3ith /I< ris4 behaviour. Coor!inate! mental health an! se@ual an!
repro!uctive health services to meet the nee!s o" universit stu!ents 3oul! be !esirable.
0o to"
Introduction
9he in"ection rate o" human immuno!e"icienc virus %/I<&)acFuire! immuno!e"icienc
sn!rome %AIDS& in Ivor Coast is estimate! at -.1C in a!ults a6es 1+(,*. Ivor Coast
has a 6eneralise! /I< epi!emic 3ith the hi6hest prevalence rate in the ?est A"rican
re6ion. Populations at comparativel hi6h ris4 "or /I< in"ection inclu!e 3omen a6es 20(
2, an! outh L1M. /i6h /I< ris4 behaviour has been reporte! amon6 outh in Abi!Aan1
Ivor Coast L2M.
Poor mental health is a maAor cause o" morbi!it in mi!!le=income countries1 3ith
!epression constitutin6 the heaviest !isease bur!en L3M. 9he /I< epi!emic contributes to
increase! !epression rates both in persons 3ho live 3ith /I< L,M an! in those 3ho are
in!irectl a""ecte! b /I<)AIDS L+M. Several revie3s in the 6eneral population in!icate
that there ma be a relationship bet3een poor mental health inclu!in6 substance use an!
chil!hoo! abuse an! /I< ris4 behaviour such as multiple se@ual partners an! unprotecte!
se@ LB=1+M.
Stu!ies 3ith universit stu!ents "oun! that an@iet L1BM1 !epression L1B11-M1
pscholo6ical !istress L1-M1 alcohol use L1-=22M1 !ru6 use L21122M an! traumatic
e@periences L23M1 in particular chil!hoo! abuse1 phsical abuse an! especiall se@ual
abuse L2,M1 3ere associate! 3ith various "orms o" /I< ris4 behaviour. Currentl1 there is
no su""icient !ata on universit stu!ents re6ar!in6 the association bet3een mental
!isor!ers1 chil!hoo! abuse an! /I< se@ual ris4 behaviour 3ithin the ?est A"rican
conte@t. 9here"ore1 the aim o" this stu! 3as to !etermine the association bet3een mental
health1 chil!hoo! abuse an! /I< se@ual ris4 behaviour amon6 Jeli@ /ouphouft Goi6n
>niversit un!er6ra!uate stu!ents in Ivor Coast.
0o to"
%ethods
Sample and procedure
A cross=sectional surve !esi6n 3as use!. An anonmous1 sel"=a!ministere!
Fuestionnaire 3as use! to collect !ata. Concernin6 the samplin6 proce!ure1 3e con!ucte!
a simple ran!om samplin61 strati"ie! an! 3ei6hte! on the siKe o" units o" trainin6 an!
research %>95& o" Jeli@ /ouphouft Goi6n >niversit. In!ee!1 "rom the siKe o" the
!i""erent units o" trainin6 an! research %"aculties&1 3e !etermine! the percenta6e 3ei6ht
o" each unit trainin6 an! research %"acult& compare! to the total number o" stu!ents at
the Jeli@ /ouphouft Goi6n >niversit. 9hen1 3e assi6ne! this percenta6e to '00
stu!ents in Fuestion1 3hich 6ave us the number o" stu!ent per unit trainin6 an! research
or "acult. In each >951 3e con!ucte! a simple ran!om sample rate. Permission to carr
out the stu! 3as obtaine! "rom the Presi!ent o" Jeli@ /ouphouft Goi6n >niversit an!
ethical clearance 3as also ta4en. 9he cover pa6es o" the Fuestionnaires brie"l e@plaine!
about the stu! an! provi!e! instructions to the respon!ents on ho3 to "ill it up. It also
provi!e! in"ormation about the researchers. It also mentione! that anonmit an!
con"i!entialit 3oul! be maintaine! an! that the participation o" stu!ents 3as voluntar.
It speci"ie! that !ata 3oul! be use! onl "or research purposes. ?ritten in"orme! consent
3as ta4en "rom participatin6 stu!ents1 an! the stu! 3as con!ucte! "rom - Januar to '
Jebruar 2013.
%easures
!raumatic e/periences
Participants 3ere as4e! i" the ha! ever been hit b a se@ partner1 "orce! to have se@1
phsicall abuse! as a chil!1 se@uall abuse! as a chil! an! !ia6nose! as /I< positive.
9raumatic e@perience items 3ere co!e! as es)no L2+M.
Post-traumatic stress disorder
A seven=item screener %. D 0.--& 3as use! to i!enti" post=traumatic stress !isor!er
%P9SD& smptoms in the past month L2+12BM. Items as4e! 3hether the respon!ent ha!
e@perience! !i""iculties relate! to a traumatic e@perience %e.6.1 [Di! ou be6in to "eel
more isolate! an! !istant "rom other peopleYV an! [Di! ou become Aump or 6et easil
startle! b or!inar noises or movementsYV&. Consistent 3ith epi!emiolo6ical evi!ence1
participants 3ho ans3ere! a""irmativel to at least "our o" the Fuestions 3ere consi!ere!
to have a positive screen "or P9SD L2+12BM.
Depressi-e symptoms
?e assesse! depressie symptoms usin6 the ten=item version o" the Center "or
Ipi!emiolo6ic Stu!ies Depression %CIS=D& scale L2-M. ?hile the CIS=D ten=item surve
has not been !irectl compare! to clinical !ia6nosis o" maAor !epression1 the sensitivit
an! speci"icit o" the CIS=D 20=item surve has been reporte! to avera6e '0C an! -0C1
respectivel1 compare! to "ormal !ia6nostic intervie3 L2'M. Scorin6 is classi"ie! "rom 0 to
* as havin6 mil! level o" !epressive smptoms1 10 to 1, as mo!erate !epressive
smptoms1 an! N1+ representin6 severe !epressive smptoms L2*M. 9he Cronbach .
reliabilit coe""icient o" this ten=item scale 3as 0.-2 in this stu!.
Alcohol consumption
(lcohol consumption 3as measure! b as4in6 participants 3hich o" the "ollo3in6 terms
best !escribe! them# non=!rin4er1 special occasion !rin4er1 occasional an! re6ular
!rin4er. $ccasional an! re6ular !rin4ers 3ere as4e!1 [ho3 o"ten !o ou have %"or men&
"ive or more an! %"or 3omen& "our or more !rin4s on one occasionYV 5esponse options
ran6e! "rom 1 D never to + D !ail or almost !ail.
/I< ris4 behaviour items 3ere !evelope! base! on literature revie3 L2+130131M an!
assesse! "our components o" /I< ris41 number o" se@ual partners1 protecte! or
unprotecte! se@ual intercourse1 alcohol use in the conte@t o" se@ an! histor o" a se@uall
transmitte! in"ection %S9I&. /I< ris4 behaviour1 there"ore1 3as assesse! 3ith "our items1
number o" se@ual partners in the past 12 months1 con!om use consistenc in the past 3
months 3ith primar partner1 alcohol use in the conte@t o" se@ in the past 3 months an!
ever havin6 been !ia6nose! 3ith an S9I.
Socioeconomic bac46roun! 3as assesse! b havin6 stu!ents rate their "amil bac46roun!
as 3ealth %3ithin the hi6hest 2+C in Ivor Coast1 in terms o" 3ealth&1 Fuite 3ell o""
%3ithin the +0C to -+C ran6e "or their countr&1 not ver 3ell o"" %3ithin the 2+C to
+0C ran6e "rom Ivor Coast& or Fuite poor %3ithin the lo3est 2+C in their countr1 in
terms o" 3ealth&. ?e subseFuentl !ivi!e! the stu!ents into poorer %not ver 3ell o"" an!
Fuite poor& an! 3ealthier %3ealth1 Fuite 3ell o""& cate6ories.
"eli'iousness
+eligiousness 3as assesse! 3ith the "ive=item Du4e >niversit 5eli6ion In!e@ %D>5I8&
L32M. 9he instrument assesses the three maAor !imensions o" reli6iosit# or6aniKational
reli6ious activit1 non=or6aniKational reli6ious activit1 an! intrinsic reli6iosit %or
subAective reli6iosit& L33M. 9he D>5I8 measures each o" these !imensions b a
[separate subscaleV 1 an! correlations 3ith health outcomes are analse! b subscale in
separate mo!els L33M. Cronbach alpha "or the intrinsic reli6iosit scale 3as 0.B0 "or this
sample.
Data analysis
9he !ata 3ere analse! usin6 IGM SPSS %version 20.0&. Jirst1 6en!er !i""erences 3ere
analse! "or all variables usin6 chi=sFuare tests. Since there 3ere si6ni"icant 6en!er
!i""erences on a number o" variables1 subseFuent mo!els 3ere analse! separatel "or
men an! 3omen. Secon!1 lo6istic re6ression analses 3ere !one to i!enti" traumatic
e@periences that 3ere in bivariate analsis associate! 3ith a positive screen "or P9SD
an! a positive screen "or !epression L2+M. 9hir!1 lo6istic re6ression 3as use! to i!enti"
"actors that 3ere associate! 3ith /I< ris4 behaviour. Pre!ictor variables 3ere entere! in
a sin6le step.
0o to"
"esults
Sample characteristics
$" the 'B0 stu!ents approache! "or the stu!1 '2, a6ree! to participate in the surve
%*BC response rate&. 9he sample inclu!e! '2, universit stu!ents %+0C men an! +0C
3omen&1 3ith a mean a6e o" 23.- ears %SD D 2.-&1 ,3.2C stu!in6 in their "irst ear1
22.'C secon! ear1 21.BC thir! ear an! 12.,C "ourth ear1 an! '2.*C 3ere "rom a
poorer "amil bac46roun!. Most stu!ents 3ere1 b reli6ious a""iliation1 Christians
%--.BC& an! Muslims %1-.+C&. 5e6ar!in6 mental health1 1-.BC reporte! !epression1
10.'C screene! positive "or P9SD an! '.3C reporte! at least monthl heav episo!ic
!rin4in6. Chil!hoo! phsical abuse 3as 13.+C an! se@ual abuse ,.-C. /i6h /I< ris4
behaviour 3as reporte!# 33.*C ha! t3o or more se@ual partners in the past 12 months1
BB.3C ha! inconsistent con!om use1 23.BC ha! alcohol use in the conte@t o" se@ an!
1B.-C ha! a histor o" a S9I. Goth 3omen an! men in!icate! that the 3ere subAecte! to
partner violence1 3ith 21.2C o" 3omen reportin6 se@ual violence. Je3 %1.1C& in!icate!
that the 3ere /I< positive %see 9able 1&.
Table 1
.ample characteristics
Predictors of multiple se/ual partners
In bivariate analsis amon6 men1 lac4 o" or6anise! an! non=or6anise! reli6ious activities1
lac4 o" intrinsic reli6iosit1 heav episo!ic !rin4in61 alcohol use in the conte@t o" se@ an!
havin6 screenin6 positive "or !epression 3ere associate! 3ith t3o or more se@ual
partners in the past 12 months. In multivariate analsis amon6 men1 lac4 o" non=
or6anise! reli6ious activit an! alcohol use in the conte@t o" se@ 3ere associate! 3ith
t3o or more se@ual partners in the past 12 months. Jurther1 in bivariate analsis amon6
3omen1 poorer "amil bac46roun!1 lac4 o" non=or6anise! reli6ious activit1 lac4 o"
intrinsic reli6iosit1 e@perience o" phsical an! se@ual partner violence an! alcohol use in
the conte@t o" se@ 3ere associate! 3ith t3o or more se@ual partners in the past 12
months. In multivariate analsis amon6 3omen1 poorer "amil bac46roun!1 e@perience o"
se@ual partner violence an! alcohol use in the conte@t o" se@ 3ere associate! 3ith t3o or
more se@ual partners in the past 12 months. Amon6 both men an! 3omen1 chil!hoo!
phsical an! se@ual abuse 3as not "oun! to be associate! 3ith multiple se@ual partners
%see 9able 2&.
Table 2
8o6istic re6ression anal#ses predictin6 multiple se4ual partners
Predictors of inconsistent condom use
In bivariate analsis amon6 men1 onl other reli6ious a""iliation 3as associate! 3ith
inconsistent con!om use in the past 3 months. Jurther1 in bivariate analsis amon6
3omen1 e@perience o" phsical an! se@ual partner violence 3as associate! 3ith
inconsistent con!om use in the past 3 months. In multivariate analsis amon6 3omen1
e@perience o" phsical partner violence remaine! associate! 3ith inconsistent con!om
use in the past 3 months %see 9able 3&.
Table &
8o6istic re6ression anal#ses predictin6 inconsistent condom use
Predictors of history of S!I
In bivariate analsis amon6 men1 lac4 o" non=or6anise! reli6ious activit an! alcohol use
in the conte@t o" se@ 3ere associate! 3ith a histor o" S9I1 3hile in multivariate analsis1
lac4 o" non=or6anise! reli6ious activit remaine! associate! 3ith a histor o" S9I.
Jurther1 in bivariate analsis amon6 3omen1 alcohol use in the conte@t o" se@ an! havin6
screene! positive 3ith !epression 3ere associate! 3ith a histor o" S9I1 3hile
multivariate analsis havin6 screene! positive 3ith !epression remaine! associate! 3ith
a histor o" S9I %see 9able ,&.
Table $
8o6istic re6ression anal#ses predictin6 histor# o! .TI
0o to"
Discussion
9his stu! "oun! a hi6h prevalence o" poor mental health %!epression an! P9SD
smptoms&1 hi6h reporte! chil!hoo! phsical an! se@ual abuse an! hi6h /I< ris4
behaviour %multiple se@ual partners1 unprotecte! se@1 alcohol in the conte@t o" se@ an!
histor o" S9I& amon6 a sample o" universit stu!ents in Ivor Coast. 9he hi6h
prevalence o" /I< ris4 behaviour is callin6 "or /I< prevention intervention pro6rams
amon6 universit stu!ents.
9he prevalence o" !epression an! P9SD 3as similar to other stu!ies in A"rica L1B13,=3BM.
9he stu! "oun! that poor mental health %!epression& inclu!in6 alcohol use 3as
associate! 3ith /I< ris4 behaviour amon6 this sample o" universit stu!ents in Ivor
Coast. 9his "in!in6 is in concor!ance 3ith previous stu!ies amon6 universit stu!ents
L1B11-11*=23M. ?hile associations bet3een alcohol use L1-=22M an! /I< ris4 behaviours
have previousl been "oun! amon6 universit stu!ents1 the mechanisms e@plainin6 the
association bet3een alcohol use an! /I< ris4 behaviours in this settin6 are not "ull
un!erstoo! L1-M. Alcohol use in the conte@t o" se@ an! bin6e !rin4in6 seem to be
associate! in particular 3ith in!iscriminate "orms o" ris4 se@ %e.6.1 havin6 multiple or
casual se@ partners&1 3hich is 4eepin6 3ith the stu!ies o" American colle6e populations
L3-13'M.
9he prevalence o" chil!hoo! phsical an! se@ual abuse 3as in this stu! %1-.-C an!
*.2C phsical abuse amon6 men an! 3omen1 respectivel1 an! 3.'C an! +.BC se@ual
abuse amon6 men an! 3omen1 respectivel& similar to 3hat 3as "oun! in communit
samples in South A"rica1 9anKania an! Ximbab3e %1,.*C(2-.,C an! ,.3C(1+.BC
phsical abuse amon6 men an! 3omen1 respectivel1 an! 1.BC(,.+C an! 2.,C(,.*C
se@ual abuse amon6 men an! 3omen1 respectivel& L1+M. Contrar to some other stu!ies
L1+12,13*M1 this stu! !i! not "in! an association bet3een chil!hoo! phsical an! se@ual
abuse an! /I< ris4 behaviour. 9he stu! "oun! that amon6 3omen1 the e@perience o"
phsical an!)or se@ual partner violence 3as associate! 3ith /I< ris4 behaviour. As "oun!
in other stu!ies L231,0=,,M 3omen 3ho e@perience intimate partner violence are at ris4
"or /I< throu6h hi6h=ris4 heterose@ual contact. $verall1 poor mental health1 traumatic
e@periences an! substance use ma sner6isticall interact to increase /I< ris4 behaviour
L2BM.
9he stu! "oun! that amon6 men1 lac4 o" reli6iousness 3as associate! 3ith /I< ris4
behaviour %multiple se@ual partners an! histor o" S9I&1 but it 3as not associate! 3ith
con!om use. Similarl1 in a stu! amon6 universit stu!ents in >6an!a "or those 3ho
rate! reli6ion as less important in their "amil1 the probabilit o" havin6 a hi6h number o"
li"etime partners increase! si6ni"icantl1 3hile the role o" reli6ion seeme! to have no
impact on con!om use L,+M. 5eli6ious belie"s an! attitu!es on se@ual matters appear to
have consi!erable in"luence on the se@ual con!uct o" oun6 men in the Ivor Coast L,BM
3hich can be utilise! "or /I< prevention pro6rams. Jinall1 3omen "rom poorer "amil
bac46roun!s 3ere more li4el to be en6a6in6 in se@ 3ith multiple partners. It is possible
that stu!ents "rom poorer bac46roun!s en6a6e more li4el in transactional se@ L,-M.
Study limitations
8imitation pertains to the 6eneraliKabilit o" the stu! results1 3here caution shoul! be
ta4en 3hen interpretin6 these results1 as onl "ull=time un!er6ra!uate stu!ents bet3een
the a6es o" 1' to 30 ears 3ere inclu!e! in this stu!. It is un4no3n to 3hat e@tents these
"in!in6s can be 6eneralise! to part=time or non=resi!ent stu!ents. 9he !ata use! in the
stu! 3ere obtaine! b sel"=report 3hich coul! have been the result o" !esire!
participants: responses. Althou6h the stu! 3as anonmous1 the sensitive nature o" the
items relate! to se@ual behaviour coul! have an impact on the participants: responses.
Moreover1 this stu! 3as base! on the !ata collecte! in a cross=sectional surve. ?e
cannot1 there"ore1 ascribe causalit to an o" the associate! "actors in the stu!. A "urther
limitation 3as that certain mental health measures 3ere brie" screenin6s an! ma be
interprete! onl as in!icators o" poor mental health L2B12-M. In a!!ition1 the stu! !i! not
screen "or the histor o" severe mental illness1 3hich has been "oun! to be associate! 3ith
/I< ris4 behaviour L,,M1 an! shoul! be inclu!e! in "uture stu!ies.
0o to"
Conclusions
/i6h rates o" !epression1 P9SD1 chil!hoo! abuse an! /I< ris4 behaviour 3ere "oun!
amon6 the stu!ie! universit stu!ent population. Poor mental health %!epression&
inclu!in6 alcohol use an! partner violence 3as associate! 3ith /I< ris4 behaviour.
Coor!inate! mental health an! se@ual an! repro!uctive health services to meet the nee!s
o" universit stu!ents 3oul! be !esirable.
0o to"
Competin' interests
9he authors !eclare that the have no competin6 interests.
0o to"
AuthorsI contributions
2P 3as the main contributor to the conceptualiKation o" the stu!. 2P an! SP contribute!
si6ni"icantl to the "irst !ra"t o" the paper1 an! 2P1 SP an! I9 contribute! to the
subseFuent !ra"ts an! "inaliKation. All authors rea! an! approve! the "inal manuscript.
0o to"
Ac3nowled'ements
Partial "un!in6 "or this stu! 3as provi!e! b the South A"rican Department o" /i6her
I!ucation.
0o to"
"eferences
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Jurnal '
GMC Public /ealth. 2013; 13# 20,.
Publishe! online 2013 March -. !oi# 10.11'B)1,-1=2,+'=13=20,
PMCID# PMC3B00001
Symptoms of common mental disorder
and co'niti-e associations with
seropositi-ity amon' a cohort of people
comin' for testin' for HIV1AIDS in *oa;
India: a cross-sectional sur-ey
5osie Maston1
1
<i4ram Patel1
213
Melanie Abas1
1
Pria 2or6aon4ar1
3
5amesh ParanAape1
,
Savio 5o!ri6ues1
+
an! Martin Prince
1
Author in"ormation 7 Article notes 7 Copri6ht an! 8icense in"ormation 7
;o to#
Abstract
+ac3'round
9he maAorit o" research on /I<)AIDS an! mental health has been carrie! out amon6
clinical populations# the time o" onset o" comorbi! !epression an! the mechanisms "or
this are there"ore unclear. Althou6h there is evi!ence to su66est that asmptomatic people
livin6 3ith /I<)AIDS e@hibit some co6nitive !e"icits1 the prevalence o" poor co6nitive
"unctionin6 amon6 people in lo3 income settin6s at an earl1 pre=clinical sta6e has not
et been investi6ate!.
%ethods
?e use! a cross=sectional surve !esi6n to test the hpotheses that smptoms o"
Common Mental Disor!er %CMD& an! lo3 scores on co6nitive tests 3oul! be associate!
3ith seropositivit amon6 participants comin6 "or testin6 "or /I<)AIDS. Participants
3ere recruite! at the time o" comin6 "or testin6 "or /I<)AIDS; voluntar in"orme!
consent 3as sou6ht "or participation in research intervie3s an! !ata lin4a6e 3ith /I< test
results. Gaseline Fuestionnaires inclu!in6 socio!emo6raphic variables an! measures o"
mental health %P/E=*1 ;AD=-1 panic !isor!er Fuestions1 A>DI9 an! !elae! 3or! list
learnin6 an! recall an! animal namin6 test o" verbal "luenc& 3ere a!ministere! b
traine! intervie3s. /I< status !ata 3as e@tracte! "rom clinical recor!s.
"esults
CMD an! scorin6 belo3 the e!ucational norm on the test o" verbal "luenc 3ere
associate! 3ith testin6 positive "or /I<)AIDS in bivariate analsis %$5 D 2.2B1 1.31=
3.*3; $5D 1.--1 1.2B=2.,'1 respectivel&. A"ter controllin6 "or the e""ects o" con"oun!ers1
the association bet3een CMD an! seropositivit 3as no lon6er statisticall si6ni"icant
%A$5D 1.+B1 0.'B=2.'+&. A"ter a!Austin6 "or the e""ects o" con"oun!ers1 the association
bet3een lo3 scores on the test o" verbal "luenc an! seropositivit 3as retaine! %A$5D
1.--1 1.2-=2.,'&.
Conclusions
$ur "in!in6s provi!e tentative evi!ence to su66est that lo3 co6nitive test scores %an!
possibl !epressive smptoms& ma be associate! 3ith /I< status amon6 people 3ho
have et to receive their /I< test results. Impaire! co6nitive "unctionin6 an! !epression=
li4e smptoms ma be the result o" the same un!erlin6 neurolo6ical !ama6e. CMD an!
co6nitive impairment ma overlap to a 6reater e@tent than previousl assume!. I"
replicate!1 this ma have implications "or the 3a in 3hich 3e measure an! treat CMD
an! co6nitive "unctionin6 amon6 people livin6 3ith /I<)AIDS.
;o to#
+ac3'round
/i6h levels o" common mental !isor!er have been i!enti"ie! amon6 people livin6 3ith
/I<)AIDS in communities aroun! the 3orl! L1=+M1 inclu!in6 in In!ia LBM. 9here is
evi!ence "rom lo3 an! mi!!le income an! hi6h income settin6s that Common Mental
Disor!ers %CMD& such as !epression have an a!verse impact upon a!herence L-=*M1 as
3ell as a!!itional ne6ative e""ects upon /I<=relate! clinical outcomes such as !isease
pro6ression an! survival1 that are in!epen!ent o" the e""ects o" common mental !isor!er
upon a!herence L10111M. .euroco6nitive impairment usuall thou6ht to be !ue to /I<=
relate! !ama6e to the "rontostriatal re6ion o" the brain is 6enerall "oun! to occur amon6
20(3- percent o" people livin6 3ith /I<)AIDS L12M an! is associate! 3ith /I<=
associate! !ementia1 !isease severit L13M1 mortalit L1,M1 a!herence to antiretroviral
therap L1+M an! emploment L1BM. 9he precise mechanisms "or the hi6h prevalence o"
comorbi! neuroco6nitive impairment 3ith /I<)AIDS are not 3ell un!erstoo! but recent
stu!ies have "oun! re!uce! subcortical volumes an! metabolite abnormalities amon6
/I<=positive participants on cA59 L1-M.
Althou6h !ia6nosis an! li"e events relate! to !ia6nosis an! !isclosure un!oubte!l
contribute to the poor mental health o" people livin6 3ith /I<)AIDS L1'11*M1 there is
evi!ence to su66est that the presence o" /I< in the brain ma also pla a role in
pro!ucin6 !epression=li4e smptoms L20M. 9he maAorit o" research on /I<)AIDS an!
mental health has been carrie! out amon6 clinical populations# the time o" onset o"
comorbi! !epression an! the mechanisms "or this are there"ore unclear. Althou6h there is
evi!ence to su66est that asmptomatic people livin6 3ith /I<)AIDS e@hibit some
co6nitive !e"icits L21M1 the prevalence o" poor co6nitive "unctionin6 amon6 people in lo3
income settin6s at an earl1 pre=clinical sta6e has not et been investi6ate!.
9he "e3 researchers 3ho have measure! !epression amon6 people comin6 "or testin6 in
lo3 income settin6s have 6enerall "oun! a hi6h prevalence %,+ percent in an In!ian
sample LBM; ,1 percent amon6 pre6nant 3omen in South A"rica L22M&. Depression 3as not
"oun! to be associate! 3ith testin6 positive "or /I<)AIDS in either these samples.
9he limite! !ata available on /I<=associate! co6nitive impairment in lo3 income
settin6s 6enerall in!icates lo3er co6nitive "unctionin6 amon6 seropositive participants
as compare! to serone6ative controls L12M. Prevalence estimates o" impairment var= a
multicentre ?/$ surve "oun! impairment amon6 smptomatic in!ivi!uals o" bet3een
13 an! 1* percent L21M1 3hereas recent stu!ies carrie! out in In!ia1 China1 >6an!a an!
Gots3ana comparin6 /I<=positive 3ith /I<=ne6ative controls reporte! prevalence o"
bet3een 31 an! +B percent L12123M.
9he aim o" the >mee! stu! 3as to investi6ate the relationship bet3een CMD smptoms
co6nitive "unctionin6 an! /I<)AIDS amon6 a cohort o" people atten!in6 a public clinic
"or /I<=testin6. At the time o" intervie31 stu! participants 3ere not a3are o" their /I<
status. ;iven the evi!ence to support a biolo6ical path3a bet3een /I< in"ection an!
common mental !isor!er an! co6nitive impairment1 3e hpothesise! that CMD
smptoms an! co6nitive impairment 3oul! pre!ict testin6 positive "or /I<)AIDS amon6
a sample that 3ere not et a3are o" the outcome o" their test.
;o to#
%ethods
Desi'n
Analsis o" cross=sectional !ata "rom the O>mee!P cohort is presente! here. Participants
3ere recruite! at the time o" atten!in6 "or pre=test counsellin6 an! testin6 "or /I<)AIDS
at ;oa Me!ical Colle6e. Structure! intervie3s inclu!in6 Fuestions about !emo6raphics1
/I<=relate! "actors1 as 3ell as measures o" CMD smptoms an! alcohol an! substance
misuse 3ere carrie! out in the clinic settin6 at the time o" atten!ance "or pre=test
counsellin6 an! testin6. Participants 3ere then "ollo3e! up via routine recor!s in or!er to
obtain /I< status an! atten!ance o" post=test counsellin6 !ata.
In or!er to test the hpothesis that CMD smptoms an!)or co6nitive impairment 3oul!
pre!ict seropositivit amon6 those 3ithout 4no3le!6e o" their /I< status1 stu!
participants 3ho reporte! havin6 previousl been teste! "or /I<)AIDS an! 3ho ha!
receive! a seropositive result 3ere e@clu!e! "rom analses %n D +-& presente! in 9ables 11
121 21 131 31 1, , an! an!+ +.
9able 1
Characteristics o" the sample
9able 2
Givariate associations o" 3ith testin6 positive "or /I<)AIDS
9able 3
Multivariate mo!els a!Austin6 "or con"oun!ers o" association bet3een CMD smptoms
an! testin6 seropositive
9able ,
Multivariate mo!els a!Austin6 "or con"oun!ers o" association bet3een lo3 co6nitive
"unctionin6 score %test 1& an! testin6 seropositive
9able +
Multivariate mo!els a!Austin6 "or con"oun!ers o" association bet3een lo3 co6nitive
"unctionin6 score # verbal "luenc an! testin6 seropositive
Settin'
;oa1 the smallest In!ian state b area1 is situate! on the 3est coast bet3een Maharashtra
an! 2arnata4a an! has a population o" 1.3, millions %;overnment o" ;oa1 2010&. Jor
/I<)AIDS surveillance1 ;oa is !ivi!e! into t3o !istricts# the north is !escribe! as one o"
In!iaVs hi6h prevalence !istricts1 3ith more than one percent prevalence amon6 3omen at
antenatal care. 9he south is me!ium prevalence1 3ith more than "ive percent prevalence
"oun! amon6 those atten!in6 S9I clinics %hi6h ris4 6roup& %>.AIDS1 200'&.
"ecruitment and measures
Participants 3ere recruite! at the time o" atten!in6 the lar6est public Inte6rate!
Counsellin6 H 9estin6 Centre %IC9C& "or pre=test counsellin6 an! testin6. In 200'1 20.'
percent o" atten!ees 3ere O3al4=inP1 sel"=re"errals1 3hilst the maAorit o" people teste!
atten!e! upon the recommen!ation o" a Doctor %;oa State AIDS Control Societ1 2012&.
Doctors re"er participants "or testin6 "or a variet o" reasons1 inclu!in6# une@plaine! or
suspecte! /I<=relate! smptoms1 pre=operative tests. Sel"=re"errals inclu!e those 3ho
believe themselves to be at hi6h=ris4 as 3ell as those un!er6oin6 pre=marital tests or
testin6 be"ore 6oin6 to 3or4 abroa!. Potential participants 3ere in"orme! about the stu!
b traine! research assistants; consent "or participation an! !ata lin4a6e 3ith test results
3as sou6ht. 9he stu! 3as approve! b local an! international research ethics
committees %San6ath an! 2C8&.
Euestionnaires1 a!ministere! b research assistants usin6 palmtop computers 3ere
carrie! out at the time o" participants comin6 "or testin6. In or!er to ma@imise privac
an! Fuietness1 intervie3s 3ere carrie! out in purpose=built temporar cabins situate! in
the clinic reception area. People atten!in6 the IC9C "or pre=test counsellin6 an! testin6
"or /I<)AIDS 3ere eli6ible to participate i" the met the "ollo3in6 inclusion criteria#
!emonstration o" capacit= un!erstan!in6 the aims o" the stu! an! !eman!s o"
participation an! able to 6ive in"orme! consent; "luent in one o" three local lan6ua6es
%2on4ani1 /in!i H In6lish&; a6e! more than ei6hteen ears o" a6e. Euestions relatin6 to
!emo6raphics1 /I<=relate! behaviours1 belie"s an! 4no3le!6e %transmission an!
prevention 4no3le!6e1 !isclosure plans1 se@ual behaviour1 4no3le!6e an! smptoms o"
se@uall transmitte! in"ections& an! measures o" mental health 3ere inclu!e! in baseline
intervie3s.
In or!er to access "ree=o"=char6e antiretroviral treatment services1 it is necessar to
present a test certi"icate "rom a state=run testin6 centre. 9here"ore1 testin6 in the private
sector1 "ollo3e! b re=testin6 at a public testin6 centre is relativel common. Participants
3ere there"ore as4e! i" the ha! previousl un!erta4en a /I<=test; those 3ho ha!
receive! test results 3ere as4e! to !isclose the result to intervie3ers.
C%D and alcohol use
A mo!i"ie! version o" the Patient /ealth Euestionnaire1 the brie" P/E=*1 in combination
3ith the -=item ;eneralise! An@iet Disor!er scale %;AD=-&1 plus the panic !isor!er
mo!ule L2,M 3ere inclu!e! in the baseline Fuestionnaire to measure smptoms o"
!epression1 an@iet an! panic. In a stu! comparin6 the sensitivit an! speci"icit o" "ive
screeners "or CMD in primar care 3hich carrie! out in ;oa1 the P/E 3as one o" "ive
instruments to achieve an A>C "rom 5$C analsis o" at least 0.'0 %P/E A>C D 0.',&
L2+M. In >mee!1 as recommen!e! b SpitKer et al. L2,M1 a cut=o"" o" 10 3as use! as an
in!icator "or smptoms o" maAor !epression. A cut=o"" o" 10 3as use! to in!icate
smptoms o" severe 6eneralise! an@iet L2BM. Participants reportin6 OesP to each o" the
"irst "our Fuestions relatin6 to an@iet attac4s 3ere in!icate! as panic !isor!er cases in
the >mee! stu!. At the time o" con!uctin6 the stu!1 there 3ere no measures o" an@iet
smptoms that ha! been vali!ate! in a local /I<=a""ecte! population. 9here"ore1 3e
!eci!e! to use brie" measures that sho3e! 6oo! vali!it in primar care populations
else3here. ;iven the evi!ence to support !istinctive !ia6nostic cate6ories o" !epression
an! an@iet L2-=2*M1 participants i!enti"ie! as havin6 smptoms o" maAor !epression
an!)or 6eneralise! an@iet !isor!er an!)or panic !isor!er 3ere cate6orise! as havin6
common mental !isor!er !urin6 analsis. OCMD smptomsP !oes not re"er to a clinical
!ia6nosis but to the result o" the screenin6 proce!ure use! in this epi!emiolo6ical stu!.
9he A>DI9 is a 10 item Fuestionnaire !esi6ne! to measure me!ium %cut=o"" o" ei6ht& an!
hi6h levels %cut=o"" o" 1B& o" alcohol problems %?/$ 2001&. 9he instrument has been
3i!el use! in In!ia ie. L30131M an! in stu!ies con!ucte! in ;oa L32133M. A recent vali!it
stu! con!ucte! in ;oa !emonstrate! 6oo! sensitivit an! speci"icit "or the A>DI91
3ith an area un!er the curve o" more than 0.'0 L3,M. Jor analsis1 participants 3ere
cate6orise! as haKar!ous !rin4ers i" the score! above ei6ht.
Co'niti-e functionin'
93o measures o" co6nitive "unctionin6 3ere inclu!e! in the >mee! Fuestionnaire# 3or!
list learnin6 %assessin6 memor& an! animal namin6 %measurin6 verbal "luenc1 an aspect
o" e@ecutive "unctionin61 4no3n to be a common !e"icit in people livin6 3ith /I<)AIDS=
L3+M&. 9he terms Olo3 co6nitive "unctionin6P an! Oco6nitive !e"icitsP appl to the t3o
!omains teste! onl. Due to the broa!er aims o" >mee! %investi6atin6 impact o"
pscholo6ical "actors upon access to care& an! the practicalities o" measurin6 co6nition in
a bus clinic settin61 3e use! brie"1 simple screeners to measure !omains that ma be
impacte! b /I< an! that 3ere most li4el to be implicate! in !eterminin6 access to
services.
Jor the 3or! list learnin6 test1 intervie3ers rea! out a ten 3or! list %a!apte! "or use in
In!ia= L3BM& three times. Participants 3ere then as4e! to recite the list o" 3or!s a"ter each
rea!in6 an! "inall reFueste! to recall 3or!s a"ter another section o" the Fuestionnaire
ha! been complete!. 9he "inal total recalle! 3as recor!e!. Jor the animal namin6 test1
participants 3ere as4e! to tell the intervie3er as man !i""erent tpes o" animals as the
coul! recall !urin6 one minute.
9hese tests ori6inate "rom the Consortium to Istablish a 5e6istr o" AlKheimerVs Disease
%CI5AD& test batter an! have been vali!ate! amon6 an ol!er population in ;oa as part
o" the vali!ation o" a cross=cultural !ia6nostic instrument "or !ementia L3-M. .ormative
!ata 3as available1 in the "orm o" e!ucation=speci"ic norms !erive! "rom the 10)BB stu!
!ata "or the oun6est o" the ol!er a6e=6roup %B0(B, ears&. I!ucation=speci"ic cut=points
"or possible co6nitive impairment at 1.+ stan!ar! !eviations belo3 the norms 3ere use!
in the >mee! stu! as in!icators o" lo3 co6nitive "unction.
#utcome measures
$utcome !ata 3as collecte! "rom routine clinical recor!s maintaine! b IC9C sta"" b an
>mee! team member 3ho 3as not involve! in baseline !ata collection. /I< status an!
!ate o" atten!ance o" post=test counsellin6 %i" atten!e!& 3as e@tracte! "rom IC9C recor!s.
Stu! participants recor!s 3ere i!enti"ie! usin6 the uniFue i!enti"ier assi6ne! to
participants b counsellors at pre=test counsellin6.
Analysis
Givariate analsis 3as carrie! out. chi=sFuare! tests 3ere use! to test !i""erences bet3een
!istribution o" /I< status outcome bet3een cate6ories o" a& hpothesise! e@posures o"
interest %common mental !isor!er1 co6nitive "unctionin6& an! b& potential !emo6raphic1
/I<=relate! an! pschosocial con"oun!ers. Mantel /aensKel o!!s ratios comparin6 o!!s
o" testin6 positive "or /I< amon6 e@posure cate6ories "oun! to be associate! 3ith
seropositivit in chi=sFuare! analses are presente! in 9able 1 3ith *+ percent con"i!ence
intervals.
?here there 3as evi!ence "rom bivariate analsis o" an association bet3een e@posures o"
interest an! testin6 positive "or /I<)AIDS1 multivariate analsis 3as carrie! out to
"urther test the hpotheses that CMD smptoms an! co6nitive impairment 3oul! pre!ict
seropositivit. I@posures o" interest 3ere entere! sin6l into lo6istic re6ression mo!els.
Potential con"oun!ers 3ere then entere! one=b=one. Criteria "or inclusion in "inal
mo!els 3ere# a& variables consi!ere! a priori con"oun!ers %"or e@ample1 association o"
a6e 3ith co6nitive "unctionin6&; or b& variables selecte! usin6 a Ochan6e in estimateP
metho! ie. those that resulte! in a si6ni"icant chan6e in the e""ect o" e@posure o" interest
upon outcome %more than 10 percent chan6e in o!!s ratio&.
;o to#
"esults
Characteristics of the sample
As !escribe! in 9able 11 '.' percent o" the sample teste! seropositive. 9he maAorit o" the
sample 3ere "emale %+3.0 percent&; the mean a6e o" participants 3as 3+ ears. Almost
three Fuarters 3ere /in!u %-3.0 percent& an! the maAorit 3ere born in ;oa %+B.1
percent&. Most 3ere marrie! %-0.2 percent&; 2+.1 percent ha! atten!e! up to primar
school 3hilst 1-.* percent ha! receive! no e!ucation at all. 1'.+ percent reporte! ever
havin6 e@perience! hun6er !ue to lac4 o" mone.
9he prevalence o" CMD smptoms amon6 this sample o" people o" people comin6 "or
testin6 "or /I<)AIDS 3as +.3 percent. 12.' percent o" participants reporte! haKar!ous
alcohol use %2B., percent amon6 men= not presente!&. Aroun! a Fuarter o" the sample
score! belo3 the e!ucational norm on t3o co6nitive tests o" !elae! recall %22.' percent&
an! verbal "luenc %2+.B percent&.
Analysis of associations with testin' positi-e for HIV1AIDS
As !escribe! in 9able 21 in bivariate analsis1 CMD smptoms an! scorin6 belo3 the
e!ucational norm on verbal "luenc test 3ere associate! 3ith testin6 positive %$5D 2.2-1
1.31=3.*3; $5D 1.--1 1.2B=2.,'1 respectivel&. 9here 3as a tren! to3ar!s an association
bet3een scorin6 belo3 e!ucational norm on the test o" !elae! recall an! seropositivit
%$5D 1.,11 0.*'=2.01&. /aKar!ous alcohol use 3as not associate! 3ith seropositivit.
All variables "oun! to be associate! 3ith testin6 positive are presente! in 9able 2.
Socio!emo6raphic variables associate! 3ith testin6 positive inclu!e!# a6e %$5D 1.0*1
1.00=1.1'&1 lan6ua6e %those spea4in6 2on4ani or In6lish 3ere less li4el to test positive
than those spea4in6 /in!i# $5D 0.B+1 0.,-=0.*0; $5D 0.121 0.02=0.'+1 respectivel&1
bein6 born outsi!e o" ;oa %$5D 1.'-1 1.3+=2.+'&1 bein6 3i!o3e! %$5D 2.221 1.3B=3.B3&1
havin6 e@perience! hun6er !ue to lac4 o" mone %$5D 2.231 1.+B=3.B3&. <isitin6
relatives or "rien!s %or receivin6 visits& less than once a 3ee4 3as associate! 3ith
seropositivit %$5D 1.+31 1.2+(1.''1 $5D 1.3'1 1.1,=1.BB1 respectivel&. I!ucation 3as
associate! 3ith a re!uce! li4elihoo! o" testin6 positive %$5D 0.-01 0.+'=0.',&.
A number o" /I<=relate! variables 3ere also associate! 3ith seropositivit1 inclu!in6#
plannin6 not to !isclose test results %$5D 1.-B1 1.22=2.++&1 havin6 se@ 3ith someone
other than a re6ular partner %$5D 1.+'1 1.02=2.,,&1 havin6 se@ in e@chan6e "or cash1 6i"ts
or "avours %$5D 2.'*1 1.23=B.--&1 believin6 it is li4el that the test result 3ill be positive
%$5D 11.*,1 +.-2=2,.*1&1 havin6 a chil!)partner 3ho is livin6 3ith /I<)AIDS %$5 D
10.321 B.+,=1B.30&.
<ariables teste! but not "oun! to be associate! 3ith /I< status %results not presente! in
table& inclu!e!# internalise! %p D 0.1B& an! anticipate! sti6ma %p D 0.,0&1 4no3le!6e o"
/I< prevention %0.3'& an! transmission %p D 0.1'&.
9able 3 sho3s that1 a"ter controllin6 "or the e""ects o" con"oun!ers %e!ucation1 e@perience
o" hun6er !ue to lac4 o" mone1 !isclosure plans1 6enital 3arts1 perceive! li4elihoo! o"
testin6 positive an! verbal "luenc&1 the association bet3een CMD smptoms an!
seropositivit is no lon6er statisticall si6ni"icant %A$5 D 1.+B1 0..'B=2.'+&. As presente!
in 9able ,1 the tren! to3ar!s an association bet3een !elae! recall an! testin6 positive is
eliminate! b the a!!ition o" con"oun!in6 variables %a6e1 e!ucation1 e@perience o"
hun6er !ue to lac4 o" mone1 perceive! li4elihoo! o" testin6 positive1 verbal "luenc& to
the mo!el %A$5D 1.021 0.B'=1.+1&.
/o3ever1 as can be seen in 9able +1 althou6h the a!!ition o" potential con"oun!ers o" the
association bet3een verbal "luenc an! seropositivit %a6e1 e!ucation1 lan6ua6e1 marital
status1 CMD smptoms1 havin6 a chil!)partner 3ho is seropositive1 perceive! li4elihoo!
o" testin6 positive& re!uce! the e""ect siKe1 in the "inal mo!el1 verbal "luenc remains
si6ni"icantl associate! 3ith testin6 positive "or /I<)AIDS %A$5 D 1.--1 1.2-=2.,'&.
;o to#
Discussion
9he >mee! cohort is the lar6est stu! to !escribe the mental health o" people comin6 "or
testin6 "or /I<)AIDS in a lo3 income settin6. 9he inclusion o" seropositive an!
serone6ative atten!ees o" /I< testin6 provi!e! us 3ith a uniFue opportunit to test
hpotheses about mental health an! /I< status in the absence o" the impact o" !ia6nosis
an! conseFuent e@periences o" livin6 3ith /I<)AIDS upon participantVs mental health.
?e hpothesise! that CMD smptoms an! co6nitive impairment 3oul! be associate!
3ith testin6 positive. $ur "in!in6s 3ere inconclusive. Althou6h CMD smptoms 3as
stron6l associate! 3ith testin6 positive in bivariate analses1 a"ter a!Austment "or
con"oun!ers1 the e""ect siKe o" this association 3as re!uce! an! no lon6er statisticall
si6ni"icant. ?e "oun! some evi!ence to support the hpothesise! association bet3een lo3
co6nitive "unctionin6 an! seropositivit. Althou6h there 3as onl a bivariate tren!
to3ar!s an association bet3een !elae! recall an! seropositivit1 scorin6 belo3
e!ucation=a!Auste! norms on the test o" verbal "luenc %animal namin6& 3as associate!
3ith testin6 positive "or /I<)AIDS %A$5D 1.--1 1.2-=2.,'&.
Almost all o" the lar6e bo! o" research about /I<)AIDS an! CMD in lo3 an! mi!!le
income settin6s has been carrie! out amon6 sin6le 6roups1 3ith a /I<=positive !ia6nosis1
3ithout comparison 3ith serone6ative controls %"or e@ample1 L+13'13*M&. A "e3 stu!ies
have compare! prevalence o" !epression bet3een seropositive an! serone6ative 6roups
%ie. L,1,0M&. In one o" the "e3 stu!ies similar in !esi6n to >mee! %a sample o" test=see4ers
in Pune 3here ,+.+ percent subseFuentl receive! a positive !ia6nosis&1 univariate
analses reveale! no evi!ence o" an association bet3een common mental !isor!er an!
seropositivit LBM. In the >mee! sample1 bivariate analsis reveale! a stron6 association
bet3een CMD an! testin6 /I<=positive %$5D 2.2-1 1.31=3.*2&. /o3ever1 a"ter the
6ra!ual intro!uction o" covariates into the mo!el1 the e""ect siKe 3as re!uce! an! no
lon6er statisticall si6ni"icant %A$5D 1.+B1 0.'B=2.'+&.
Althou6h the multivariate analsis presente! in 9able 3 !emonstrates that the association
bet3een CMD smptoms an! seropositivit 3as partiall con"oun!e! b
socio!emo6raphic an! /I<=relate! covariates1 3e shoul! be cautious be"ore interpretin6
these "in!in6s as a !emonstration that there 3as no true association bet3een CMD
smptoms an! seropositivit. As in!icate! b the relativel 3i!e con"i!ence intervals
presente! in 9able 31 the lo3 prevalence o" both CMD an! seropositivit amon6 >mee!
participants %an! particularl in the sub=sample use! "or this analsis& resulte! in re!uce!
po3er to !etect an association1 there"ore 3e cannot rule out the e@istence o" a true
association bet3een CMD an! seropositivit.
As !escribe!1 the prevalence o" CMD smptoms i!enti"ie! amon6 the >mee! sample
3as much lo3er than that reporte! amon6 the t3o other samples o" people comin6 "or
testin6 in lo3 an! mi!!le income settin6s !escribe! in the literature. 9he relativel lo3
prevalence o" /I<)AIDS measure! in >mee! as compare! to these other samples %,+.+C
in In!ia; ,0.*C amon6 pre6nant 3omen in South A"rica& ma help to e@plain the
!i""erence in prevalence o" CMD smptoms. 9he >mee! sample is hetero6eneous an!
inclu!es participants at hi6h an! lo3=ris4 o" testin6 positive. 9here"ore1 it is plausible that
the overall prevalence in the >mee! sample ma be more similar to that "oun! in the
local communit L,1M1 rather than that i!enti"ie! in primar care L,2M. ?ithout "urther
research amon6 people comin6 "or testin6 in similar settin6s1 it is !i""icult to
conte@tualise our "in!in6s "urther. $" course1 the possibilit that our mo!e o"
measurement o" CMD smptoms ma have contribute! to the lo3 reporte! prevalence o"
CMD smptoms cannot be rule! out. Althou6h the P/E=* is commonl use! in ?estern
settin6s1 the lac4 o" vali!ation o" cut=points "or use amon6 /I<=a""ecte! populations in
lo3 income settin6s ma have ha! an impact upon the lo3 prevalence o" common mental
!isor!er i!enti"ie! in the >mee! cohort. As !escribe!1 all intervie3s 3ere carrie! out in
temporar1 private cabins. All participants 3ere 6iven !etaile! in"ormation about CMD
smptoms an! the aims an! obAectives o" the stu!; the P/E has been "oun! to be vali!
amon6 a ;oan sample o" people atten!in6 primar care. /o3ever1 the possibilit remains
that usin6 the P/E=* imme!iatel prior to testin6 in the bus clinic settin6 ma have
inhibite! participants 3illin6ness to !isclose potentiall sensitive in"ormation about
smptoms o" an@iet an! !epression. $ur analsis !emonstrate! a hi6h !e6ree o" co=
morbi!it o" smptoms o" an@iet an! !epression 3ithin our sample %o" those scorin6
]10 on the ;AD=-1 -+ percent score! ]10 on the P/E=*; o" those scorin6 ]10 on the
P/E=*1 20 percent score! ]10 on the ;AD=- an! ,-., percent score! bet3een + an! 10
on the ;AD=-&1 thus supportin6 the !ichotomous Osmptoms o" CMDP variable use! in
our analsis.
;iven that /I<)AIDS is associate! 3ith morbi!it1 sti6ma an! !iscrimination L,31,,M1
povert L,+M an! mortalit L,B1,-M1 it is reasonable to e@pect that livin6 3ith the !isease
contributes 6reatl to the prevalence o" CMD amon6 people 3ith /I<)AIDS. /o3ever1
there is evi!ence "rom neurolo6ical research to su66est that the in"lammator response
that contributes to the neuronal loss that causes /I<=associate! co6nitive impairment
ma also tri66er cto4ine=in!uce! !epression L20M. 5ecent research su66ests that even in
the absence o" other smptoms o" !epression an! co6nitive impairment1 /I<=relate!
!ama6e to 3hite matter ma be associate! 3ith smptoms o" apath %Ore!uce! sel"=
initiate! co6nitive1 emotional an! behavioural activitP& L,'M. In a!!ition to social an!
environmental ris4 "actors associate! 3ith their !isease status1 people livin6 3ith
/I<)AIDS %an! other chronic con!itions& ma have a biolo6ical vulnerabilit to the
!evelopment o" !epressive smptoms L,BM. Althou6h evi!ence su66estin6 that CMD ma
be associate! 3ith ris4 behaviour L,-1,*M means that a reverse relationship %pre=e@istin6
!epression promotin6 se@ual ris4=ta4in6 an! acFuisition o" /I<& cannot be rule! out1
presence o" 6enital 3arts an! perception o" /I<=ris4 3ere the onl se@ual ris4=relate!
variables1 that con"oun!e! the association bet3een CMD smptoms an! seropositivit=
there"ore this path3a seems unli4el.
9he >mee! "in!in6 that lo3 scores on the test o" verbal "luenc 3ere associate! 3ith
seropositivit correspon!s 3ith the results o" a recent meta=analsis that reveale! a
statisticall si6ni"icant !e"icit in mean scores on tests o" verbal "luenc amon6 people
livin6 3ith /I<)AIDS1 as compare! to /I<=ne6ative controls %^0.311 ^0.,, to ^0.1'&
L+0M. In the onl stu! to compare verbal "luenc bet3een seropositive in!ivi!uals an!
serone6ative controls in In!ia1 althou6h /I<=positive in!ivi!uals !i""ere! in other
lan6ua6e=relate! !omains %phonemic "luenc1 verbal 3or4in6 memor an! verbal
learnin6 an! memor&; !i""erences in animal namin6 "luenc 3ere not statisticall
si6ni"icant L+1M. Similarl1 statisticall si6ni"icant !e"icits in verbal learnin6 an! memor
3ere i!enti"ie! bet3een seropositive in!ivi!uals an! serone6ative controls in a previous
south In!ian stu! L+2M.
.eurolo6ical evi!ence supports the presence o" co6nitive !e"icits earl in the course o"
the !isease L12M. Goth co6nitive !omains measure! in >mee! %cate6or "luenc an!
verbal learnin6 an! memor& are consistent 3ith !i""use or "rontostriatal patholo61 both
o" 3hich ma be characteristic o" the e""ects o" /I<=1 on the brain L+0M. 9here is no3 a
6ro3in6 bo! o" evi!ence on the co6nitive pro"ile o" people livin6 3ith /I<)AIDS in
lo3 income settin6s1 inclu!in6 In!ia L+2M. ?hereas small stu!ies 3ith !etaile!
neuropscholo6ical assessments ten! to have strin6ent e@clusion criteria 3hich ma limit
the 6eneralisabilit o" "in!in6s1 in >mee!1 e@clusion criteria 3ere limite!1 meanin6 that
our sample 3as li4el to be more representative o" the base population. 9he aim o"
>mee! 3as to measure co6nitive "unctionin6 in the selecte! !omains most li4el to have
an impact upon lin4a6e to care an! a!herence an! to e@amine 3hether these 3ere
associate! 3ith testin6 positive. 9he animal namin6 test o" cate6or "luenc an! the 3or!
list learnin6 test o" verbal learnin6 an! memor 3ere selecte! as appropriate measures
that 3oul! be relativel Fuic4 an! simple "or traine! research assistants to a!minister
amon6 a lar6e cohort o" participants in a bus clinic settin6.
9he >mee! stu! !esi6n ha! several other metho!olo6ical stren6ths. >nli4e other stu!ies
that have investi6ate! mental health an! /I<)AIDS in a lo3 income settin61 the >mee!
stu! 3as carrie! out amon6 a lar6e sample that inclu!e! both seropositive an!
serone6ative in!ivi!uals recruite! prior to !ia6nosis. 9hus 3e 3ere able to test
hpotheses that CMD smptoms1 co6nitive "unctionin6 3oul! be associate! 3ith
seropositivit in!epen!entl o" the e""ects o" !ia6nosis. Glin! recruitment o" seropositive
an! serone6ative participants "rom the same clinic helpe! to ensure comparabilit o" the
t3o 6roups an! re!uce! ris4 o" selection bias. 9here 3as evi!ence "rom previous research
to support the vali!it o" measures o" CMD an! co6nitive "unctionin6 amon6 ;oan
populations.
/o3ever1 there 3ere also limitations. Due to ethical consi!erations1 those 3ho 3ere
potentiall most un3ell# %ie. unable to participate in 30 minute intervie3 3ithout
e@periencin6 un!ue !istress or !iscom"ort or lac4in6 capacit to un!erstan! aims1
participation !eman!s an! 6ive in"orme!1 voluntar consent& 3ere e@clu!e! "rom our
sample %n D 102&. 9here"ore1 estimates "or CMD smptoms1 lo3 co6nitive "unctionin6
an! seropositivit are li4el to be lo3er than the true prevalence amon6 people comin6
"or testin6 "or /I<)AIDS in ;oa Me!ical Colle6e. SubseFuentl1 this ma have
contribute! to smaller e""ect siKes "or associations bet3een mental health e@posures an!
/I< status.
It is possible that social !esirabilit bias ma have ha! an impact upon our measures o"
ris4=ta4in6 behaviours. 5eporte! ris4=ta4in6 behaviours 3ere "airl lo3 relative to
prevalence o" /I<# 0.1C reporte! inAectin6 !ru6s1 0.'C o" men reporte! havin6 ha! se@
3ith other men1 1.*C reporte! havin6 receive! mone or 6i"ts in e@chan6e "or se@; +C
reporte! havin6 se@ 3ith a se@ 3or4er an! 12.BC reporte! havin6 se@ 3ith someone
other than a re6ular partner in the last ear. 9his ma have limite! our abilit to control
"or the con"oun!in6 e""ects o" ris4=ta4in6 behaviours upon observe! associations bet3een
common mental !isor!er)lo3 co6nitive "unctionin6 an! /I< status.
9here 3ere other limitations to our approach to co6nitive testin6. 9he co6nitive screenin6
instruments use! in >mee! 3ere chosen because the measure! the !omains most li4el
to have an impact upon access to care. 9he e!ucation=a!Auste! norms "or co6nitive
"unctionin6 have not been vali!ate! amon6 the oun6er ;oan population or in the
conte@t o" /I<)AIDS. ?e 3ere unable to !iscriminate bet3een sub=cortical !e"icits
commonl cause! b /I< an! co6nitive !e"icits 3ith other causes %e!ucational
!eprivation1 mental sub=normalit1 lan6ua6e issues etc.&1 >nmeasure! con"oun!in6 is a
possibilit. 5everse causalit cannot be rule! out. 8o3 co6nitive test scores ma have
been cause! b a "actor other than /I< that 3as associate! 3ith /I<=ris4 an! acFuisition.
9here is evi!ence to support a lin4 bet3een heav alcohol use an! poor co6nitive
"unctionin6 L+3M1 as 3ell as an association bet3een alcohol=relate! impairment an!
re!uce! perception o" se@ual=ris4 L+,M. /o3ever1 6iven that 3e "oun! little evi!ence o"
an association bet3een alcohol use an! /I< status1 it seems unli4el that this path3a
e@plains the observe! relationship bet3een lo3 co6nitive "unctionin6 an! testin6 positive
"or /I<)AIDS.
8ac4 o" !etection o" an association bet3een !elae! recall an! seropositivit ma be !ue
to error in the measurement o" !elae! recall in >mee!. Althou6h ever e""ort 3as ma!e
to carr out intervie3s in an environment con!ucive to co6nitive testin61 it is possible
that noise an! interruptions to intervie3s ha! an impact1 particularl on measurement o"
!elae! recall1 the more comple@ o" the t3o co6nitive tests. Measurement error ma have
le! to some ran!om misclassi"ication o" !elae! recall test results1 3hich ma have
contribute! to mas4in6 a true association bet3een !elae! recall test results an! testin6
positive.
;o to#
Conclusion
>mee! stu! "in!in6s provi!e tentative evi!ence that prior to 4no3le!6e o" /I< status1
lo3 co6nitive test scores %an! perhaps CMD&1 ma be associate! 3ith seropositivit
amon6 people comin6 "or /I<=testin6. $ur "in!in6s su66est that a biolo6ical mechanism
ma contribute to the hi6h prevalence o" CMD an! poor co6nitive "unctionin6 commonl
"oun! amon6 people livin6 3ith /I<)AIDS. Impaire! co6nitive "unctionin6 an!
!epression=li4e smptoms ma be the result o" the same un!erlin6 neurolo6ical !ama6e
cause! b the presence o" /I< in the brain. CMD an! co6nitive impairment ma overlap
to a 6reater e@tent than previousl assume!. In or!er to clari" the relationship bet3een
CMD1 co6nitive impairment an! /I<)AIDS1 "urther research amon6 pre=!ia6nosis
samples is necessar. It 3oul! be help"ul to inclu!e !etaile! assessments o" 4e co6nitive
!omains. I" a closer interrelationship bet3een co6nitive "unctionin6 an! CMD amon6
people livin6 3ith /I<)AIDS is !emonstrate!1 this ma have implications "or the 3a in
3hich 3e measure an! treat CMD an! co6nitive "unctionin6 amon6 people livin6 3ith
/I<)AIDS. It 3ill be important to e@plore the possibilit o" earl behavioural mar4ers
%such as apath& as pre!ictors o" later co6nitive !ecline. Depen!in6 on the outcome o"
"uture research1 routine inte6ration o" screenin6 "or both CMD an! co6nitive !e"icits
3ithin <oluntar Counsellin6 an! 9estin6 shoul! be consi!ere!.
;o to#
Competin' interests
9he authors !eclare that the have no competin6 interests.
;o to#
AuthorsC contributions
MP H 5M conceive! o" the stu! an! planne! analses. 5M carrie! out analses. <P H
MA participate! in the !esi6n o" the stu!. 5M H P2 co=or!inate! stu! sta"" an! !ata
collection. S5 provi!e! provi!e! on=site supervision !urin6 !ata collection. 5P a!vise!
on stu! !esi6n an! ethical consi!erations. All authors rea! an! approve! the "inal
manuscript.
;o to#
Pre-publication history
9he pre=publication histor "or this paper can be accesse! here#
http#))333.biome!central.com)1,-1=2,+')13)20,)prepub
;o to#
Ac3nowled'ements
9he >mee! stu! 3as "un!e! b 6rants "rom Pschiatr 5esearch 9rust an! Par4es
Joun!ation. ?e are 6rate"ul to .ational AIDS Control $r6anisation "or approvin6 the
>mee! stu!. ?e are 6rate"ul to the >mee! research team# Priti ;irap1 Supria
/armal4ar1 5a4esh 2umar. 9han4s also to .eerAa Cho3!har1 Maram Shahmanesh1
Smita .ai4 an! the sta"" at the ;oa Me!ical Colle6e Inte6rate! Counsellin6 an! 9estin6
Centre. An! than4s to all those 3ho too4 part in the stu!.
;o to#
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in human immuno!e"icienc virus tpe 1 cla!e C=seropositive a!ults "rom South
In!ia. J .eurovirol. 200-;13%3&#1*+(202. !oi# 10.10'0)13++02'0-012+',0-.
LPubMe!M LCross 5e"M
+2. 0epthomi 91 Paul 51 <allabhaneni S1 2umarasam .1 9ate DJ1 Solomon S1
Jlani6an 9. .euroco6nitive conseFuences o" /I< in southern In!ia# a preliminar
stu! o" cla!e C virus. J Int .europschol Soc. 200B;12%3&#,2,(,30. LPubMe!M
+3. >e4ermann J1 Daum I1 Schlebusch P1 ?iebel G1 9renc4mann >. Depression an!
co6nitive "unctionin6 in alcoholism. A!!iction. 2003;*'%11&#1+21(1+2*. !oi#
10.10,B)A.13B0=0,,3.2003.00+2B.@. LPubMe!M LCross 5e"M
+,. Jromme 21 DVAmico IJ1 2atK IC. Into@icate! se@ual ris4 ta4in6# an e@pectanc
or co6nitive impairment e@planationY J Stu! Alcohol. 1***;B0%1&#+,(B3.
LPubMe!M
Jurnal (
P8oS $ne. 2012; -%11&# e,'B-1.
Publishe! online 2012 .ovember 2-. !oi# 10.13-1)Aournal.pone.00,'B-1
PMCID# PMC3+0-'-1
!he Association between Aids "elated
Sti'ma and %a5or Depressi-e Disorder
amon' HIV-Positi-e Indi-iduals in
$'anda
Dic4ens A4ena1
1121T
Se66ane Musisi1
2
John Jos4a1
1
an! Dan J. Stein
1
D. ?illiam Cameron1 I!itor
Author in"ormation 7 Article notes 7 Copri6ht an! 8icense in"ormation 7
;o to#
Abstract
+ac3'round
MaAor !epressive !isor!er in people livin6 3ith /I<)AIDS %P8?/A& is common an!
ma be associate! 3ith a number o" "actors1 inclu!in6 AIDS=relate! sti6ma1 !ecrease!
CD, levels1 increase! opportunistic in"ections an! socio!emo6raphic variables. 9he
e@tent to 3hich AIDS=relate! sti6ma is associate! 3ith maAor !epressive !isor!er amon6
P8?/A has not been 3ell stu!ie! in sub=Saharan A"rica. 9he obAective o" this stu! 3as
to e@amine the associations bet3een maAor !epressive !isor!er1 AIDS=relate! sti6ma1
immune status1 an! socio!emo6raphic variables 3ith the aim o" ma4in6
recommen!ations that can 6ui!e clinicians.
%ethods
?e assesse! 3B' P8?/A "or maAor !epressive !isor!er1 as 3ell as "or potentiall
associate! "actors1 inclu!in6 AIDS=relate! sti6ma1 CD, levels1 presence o" opportunistic
in"ections1 an! socio!emo6raphic variables.
"esults
9he prevalence o" maAor !epressive !isor!er 3as 1-.,C1 3hile -.*C o" the participants
ha! AIDS relate! sti6ma. At multivariable analsis1 maAor !epressive !isor!er 3as
si6ni"icantl associate! 3ith AIDS=relate! sti6ma L$5D 1.B+1 CI %1.20(2.2B&M1 a CD,
count o" N200 L$5 0.+2 CI %0.2-(0.**&M1 an! bein6 o" oun6er a6e L0.*+1 CI %0.*2(0.*'&.
Conclusions
Due to the hi6h bur!en o" maAor !epressive !isor!er1 an! its association 3ith AIDS
relate! sti6ma1 routine screenin6 o" P8?/A "or both con!itions is recommen!e!.
/o3ever1 more research is reFuire! to un!erstan! this association.
;o to#
Introduction
/I<)AIDS is one o" the bi66est health crises the 3orl! "aces to!a1 3ith close to t3o=
thir!s o" all people livin6 3ith /I<)AIDS %P8?/A& resi!in6 in sub=Saharan A"rica L1M.
9he prevalence o" /I<)AIDS in >6an!a in 2012 stoo! at -.2C1 3ith 3omen
!isproportionatel represente! L2M. 9he recent ministr o" health !emo6raphic surve put
the prevalence o" /I<)AIDS at '.3C in 3omen an! B.1C in men L2M. 9reatment covera6e
"or P8?/A is poor in >6an!a1 3ith onl hal" o" P8?/A accessin6 antiretroviral therap
%A59& L3M.
Amon6 P8?/A1 !epressive !isor!er is the commonest neuropschiatric !isor!er1
occurrin6 at rates t3o to three times hi6her than in /I<=ne6ative patients L,M(LBM. 9he
prevalence o" !epressive !isor!er amon6 P8?/A in >6an!a has been reporte! as 20(
,0C L-M(L10M. Depressive !isor!er in P8?/A has been associate! 3ith several critical
a!verse health= relate! outcomes. Previous 3or4 has !ocumente! poor a!herence to
me!ications1 inclu!in6 A59 in !epresse! P8?/A L11M(L13M. $ther researchers have also
!ocumente! that P8?/A su""erin6 "rom !epression pro6ress "aster "rom /I< to AIDS
compare! to non=!epresse! P8?/A L1,M(L1-M. Compare! to !epresse! /I< ne6ative
persons1 P8?/A 3ho su""er "rom !epression have also been sho3n to have a poor
Fualit o" li"e L1'M.
9he !evelopment o" !epressive !isor!er amon6 P8?/A is li4el the result o" a
combination o" biolo6ical an! socio!emo6raphic variables L1,M1 L1*M(L22M. Some o" these
biolo6ical variables ma be relativel uniFue to P8?/A1 such as AIDS=relate! sti6ma
L20M1 L21M1 compromise! immune status %lo3 CD, counts& an! increase! opportunistic
in"ections L1*M1 L23M1 L2,M. /o3ever1 socio!emo6raphic variables inclu!in6 6en!er1 lo3
e!ucation an! lac4 o" emploment have been associate! 3ith !epression in both /I<
ne6ative an! positive populations L22M1 L2+M1 L2BM
AIDS= relate! sti6ma is prominent amon6 P8?/A an! has been sho3n to ne6ativel
impact on the Fualit o" li"e1 lea!in6 to poor "unctionin6 o" a""ecte! in!ivi!uals L2-M1
L2'M. 5esearch has also sho3n that P8?/A 3ho have sti6ma are less li4el to access
/I< care services L2-M1 L2*M1 L30M1an! coul! have poor pscholo6ical 3ellbein6 L21M1
L31M. Some 3or4 !one in South A"rica has !ocumente! increase! bur!en o" AIDS sti6ma
an! its association 3ith mental !isor!ers L20M1 L32M. Despite its prominence1 AIDS relate!
sti6ma amon6 P8?/A is o"ten uni!enti"ie! L2'M1 .
9he !ual e@istence o" AIDS relate! sti6ma an! maAor !epressive !isor!er amon6 P8?/A
coul! lea! to a number o" a!verse health outcomes. /o3ever1 little 3or4 has been !one
to particularl assess the association bet3een AIDS relate! sti6ma an! maAor !epressive
!isor!er in sub=Saharan A"rica L20M1 L32M1 L33M. I@aminin6 the relationship bet3een AIDS
relate! sti6ma an! maAor !epressive coul! prove use"ul in raisin6 clinician:s a3areness
about the nee! to holisticall assess P8?/A 3ho present at P/C.
Similarl1 literature about the other "actors that ma be associate! 3ith maAor !epressive
!isor!er1 inclu!in6 immunolo6ical an! socio!emo6raphic variables in P8?/A is less
consistent. 9hus 3hile some 3or4 has reporte! that a lo3 CD, count is associate! 3ith
havin6 !epression in P8?/A L1+M1 L1-M1 other researchers have "oun! other3ise L22M1
L3,M. 5esearch "in!in6s about the association bet3een maAor !epressive !isor!er an!
"emale 6en!er L22M1 L3+M1 bein6 o" oun6er a6e L3+M(L3-M an! unemploment L3-M have
eFuall sho3n inconsistencies. I@aminin6 the association bet3een !epression an! these
"actors is important since some o" them have been sho3n to in"luence health outcomes in
P8?/A L1+M1 L1*M1 L22M.
In this stu!1 3e investi6ate! the e@tent to 3hich maAor !epressive !isor!er 3as
associate! 3ith AIDS=relate! sti6ma1 an! a number o" other variables in P8?/A 3ith
the aim o" ma4in6 recommen!ations that can 6ui!e clinicians.
;o to#
%ethods
Study desi'n and settin'
9his 3as a cross sectional stu! 3hich too4 place at the .samba /ospital /ome care
!epartment1 an /I<=P/C "acilit 3 4m "rom 2ampala cit1 bet3een the months o" April
an! June 2011.
Study population
9he stu! population consiste! o" P8?/A 3ho 3ere me!icall stable an! ha! been in
care "or atleast B months. Patients 3ere e@clu!e! i" the presente! 3ith a mental illness
reFuirin6 a!mission.
Study procedure
About 1+0(200 patients atten! the clinic !ail; each o" them is 6iven a number base! on
time o" arrival %1(200 "or e@ample&. >sin6 IPIDA9A1 3e ran!oml 6enerate! 1+(20
numbers !ail1 each number belon6in6 to a potential clinic atten!ee1 3ho 3oul! be
approache! an! in"orme! consent obtaine!. 9ria6e nurses then a!ministere! the patient
health Fuestionnaire=*%P/E=*& L3'M to screen "or !epression.
5esearch assistants1 3ho 3ere me!ical Doctors an! hol!ers o" an MGChG !e6ree1 an!
3ere traine! b the principal investi6ator1 a!ministere! the stu! instruments. 9he
presence o" a current maAor !epressive !isor!er1 accor!in6 to the Mini International
.europschiatric Inventor %MI.I& L3*M !epression mo!ule 3as con"irme! b the
research assistants. 9he presence o" bipolar !epression 3as rule! out b as4in6 3hether
patients ha! ever ha! an episo!e o" mania or hpomania. Such patients %+ in number&
3ere not inclu!e! in the "inal analsis. 9he research assistants also a!ministere! the
socio!emo6raphic Fuestionnaire an! the AIDS=relate! sti6ma scale to all consente!
patients. 9he P/E=* 3as a!ministere! as part o" a vali!ation stu!1 the "in!in6s o" 3hich
3ill be reporte! else3here. 5esearch assistants abstracte! the most recent CD, count
level "rom patient:s charts. All the Fuestionnaires 3ere translate! "rom In6lish into the
local lan6ua6e %8u6an!a&1 an! a!ministere! in either lan6ua6e1 !epen!in6 on 3hich o"
the t3o 3as un!erstoo! b the patient.
&thical appro-al
9he stu! 3as approve! b the Ma4erere >niversit School o" Me!icine Ithics
committee an! the >niversit o" Cape 9o3n /ealth Sciences /uman 5esearch Ithics
Committees. Stu! participants receive! a transport re"un! o" 101000 >6an!an shillin6s
%appro@imatel,g&.
Study instruments
9he MI.I 3as !esi6ne! as a brie" structure! intervie3 "or !ia6nosin6 the maAor A@is I
pschiatric !isor!ers in DSM=I< an! can be a!ministere! in 1'.-h11.B minutes %me!ian
1+ minutes&. 9he MI.I has been use! in a number o" stu!ies as a !ia6nostic instrument
amon6 P8?/A in >6an!a L-M1 L3+M1 L3BM1 L,0M.
AIDS relate! sti6ma scale L,1M is a * item that !evelope! "or use in sub=Saharan A"rica. It
3as vali!ate! amon6 2300 patients1 an! sho3e! 6oo! pschometric properties. 9he
internal consistenc o" the scale 3as 0.-+1 an! 3as time stable over three months r D 0.B-.
9he *= item AIDS relate! sti6ma scale taps into a broa! ran6e o" sti6matiKin6 belie"s
inclu!in6 ne6ative belie"s to3ar!s sel" an! others %internaliKe! an! enacte! variables o"
sti6ma& L,1M.
Socio!emo6raphic in"ormation1 presence o" opportunistic in"ections an! CD, counts 3as
collecte! "rom all participants usin6 a stan!ar!iKe! Fuestionnaire.
9he P/E=* 3as a!apte! "rom the primar care evaluation o" mental !isor!ers %P5IMI
MD& screenin6 Fuestionnaire "or !epressive smptoms1 an! has * Fuestions 3ith a score
ran6in6 "rom 0 to 3 "or each Fuestion %ma@imum score o" 2-&. A threshol! score o" 10 or
hi6her is consi!ere! to in!icate mil! maAor !epressive !isor!er1 1+ or hi6her in!icates
mo!erate maAor !epressive !isor!er1 an! 20 or hi6her severe maAor !epressive !isor!er.
9he internal consistenc o" the P/E=* 3as 0.B+ L,2M 9he P/E=* has not been vali!ate!
in >6an!a; ho3ever1 it 3as vali!ate! amon6 P8?/A in 2ena provi!in6 6oo!
pschometric properties 3ith a coe""icient alpha o" 0.-'. L,3M.
Study measures
A !ia6nosis o" a maAor !epressive !isor!er 3as arrive! at i" participants ha! atleast + o"
the * DSM=I<=95 smptoms "or maAor !epression1 an! 3ere Au!6e! to have social an!
occupational impairments as a result o" the smptoms. Persons !ia6nose! as !epresse!
3ere re"erre! to the atten!in6 clinic me!ical o""icer "or treatment. AIDS relate! sti6ma
3as !ia6nose! i" patients positivel en!orse! atleast + out o" the nine Fuestions. Persons
!ia6nose! 3ith AIDS=relate! sti6ma 3ere re"erre! to the hospital counsellor.
Data Analysis
Data 3as analse! usin6 S9A9A 11.2 L,,M. ?e initiall compare! in!ivi!uals 3ith an!
3ithout maAor !epressive !isor!er usin6 bivariate analsis; variables that 3ere
statisticall si6ni"icant at bivariate analsis 3ere then entere! into a multivariable mo!el
"ollo3in6 a step3ise hierarchical "ormat. 8o6istic re6ression 3as use! to test "or
si6ni"icant associations1 controllin6 "or a6e an! 6en!er. MaAor !epressive !isor!er 3as
the !epen!ent variable1 3ith AIDS relate! sti6ma1 immune status an! socio!emo6raphic
variables as in!epen!ent variables. ?e also assesse! 3hether the socio!emo6raphic an!
clinical variables 3ere con"oun!in6 the association bet3een AIDS relate! sti6ma an!
MaAor !epression.
;o to#
"esults
9he mean a6e o" the respon!ents 3as 3'.' ears %SD *.'1; ran6e 1'(-1&. $" the 3B'
participants1 -2C 3ere "emale. About t3o thir!s %B+.+C& ha! some "orm o" emploment1
an! onl 1*B %+3.'C& ha! attaine! at least secon!ar e!ucation. Mean CD,S 3as 32*.-01
%SD 1'3.*+; ran6e 1(***&. Me!ian CD,S 3as 33B1 inter=Fuartile ran6e 2+(-+C %2+0(
3+B&. 9he prevalence o" maAor !epressive !isor!er 3as 1-.,C. 93ent nine out o" the
3B' participants %-.*C& ha! AIDS relate! sti6ma. %See table 1&.
9able 1
Sociodemo'raphic and clinical characteristics of the respondents8
At bivariate analsis1 participants 3ith maAor !epressive !isor!er 3ere more li4el to
have AIDS=relate! sti6ma L$5 1.B11 CI %1.1*(2.1-&M1 an opportunistic in"ection L$5
1.'*1 CI %1.0+(3.3'&M1 an! a lo3er CD, N200& L$5 0.+2 CI %0.2-(0.**&M. Gein6 o"
oun6er a6e L$5 0.,2 CI %0.1*(0.*2&M1 lac4in6 emploment L$5 0.+31 CI %0.30(0.*1&M
an! havin6 a lo3er e!ucation L$5 0.,'1 CI %0.2-(0.',&M 3ere also associate! 3ith
!epression at bivariate analsis. %See table 2&.
9able 2
+i-ariate analysis of the sociodemo'raphic and clinical characteristics of the
respondents8
?e inclu!e! all statisticall si6ni"icant variables in the lo6istic re6ression mo!el1 an!
use! a step3ise hierarchical mo!el analsis metho!. In the "inal mo!el1 maAor !epressive
!isor!er 3as associate! 3ith AIDS=relate! sti6ma L%$5D 1.B+1 CI 1.20(2.2B&M1 CD,S
counts o" N200 L$5 0.,31 %CI 0.20(0.*1&M an! a oun6er a6e L$50.*+1 CI 0.*2(0.*'&M.
%See table 3&.
9able 3
%ulti-ariable analysis showin' associations between ma5or depression; AIDS
related sti'ma and CDG counts8
;o to#
Discussion
MaAor !epressive !isor!er 3as prevalent in our stu! population1 occurrin6 in 1-.,C o"
the participants. Previous stu!ies con!ucte! amon6 P8?/A in >6an!a have reporte!
hi6her !epression prevalence L*M1 L,+M; "in!in6s 3hich coul! be e@plaine! b the "act that
in those stu!ies1 the !ia6nosis o" !epression 3as ma!e usin6 a screenin6 instrument1
rather than a !ia6nostic one. $ur population comprise! o" me!icall stable participants
3ho 3ere 6enerall healthier1 an! this coul! e@plain the lo3er prevalence compare! to
the other >6an!an stu!ies..
AIDS=relate! sti6ma1 a con!ition that has been associate! 3ith a!verse health outcomes
in P8?/A 3as eFuall prevalent in the stu! population. $ur "in!in6 about AIDS
relate! sti6ma is also in 4eepin6 3ith previous stu!ies that have reporte! a hi6h bur!en o"
sti6ma in P8?/A L,BM(L,'M.
?e "oun! an association bet3een maAor !epressive !isor!er an! AIDS relate! sti6ma1
meanin6 that both con!itions ma be present in the same /I<=positive in!ivi!ual
atten!in6 P/C. $ur "in!in6s are in 4eepin6 3ith a previous stu! that !ocumente! an
association bet3een !epression an! sti6ma in P8?/A L1-M. Poor pschosocial
"unctionin61 the presence o" opportunistic in"ections1 poor immune status an! the "ear o"
!in6 "rom a chronic illness coul! e@plain the e@istence o" either o" these con!itions1 as
3ell as their association 3ith each other. Previous stu!ies have reporte! that sti6ma
amon6 P8?/A is associate! 3ith poor pschosocial "unctionin6 L21M1 L,*M. It:s possible
that people 3ith poor pscholo6ical "unctionin6 ma !evelop !epression.
Similarl1 the presence o" opportunistic in"ections an! poor immune status has been
associate! 3ith !epression in P8?/A L1-M1 L1*M1 L,+M. It can also be ar6ue! that
!epresse! P8?/A 3ho have opportunistic in"ections an! lo3 CD,S counts coul!
!evelop sti6ma as a result o" their con!ition. 9he "ear o" !in6 "rom a chronic illness ma
also e@plain the presence o" both con!itions. /o3ever1 the cross=sectional nature o" our
stu! ma4es it !i""icult to establish causalit1 an! the !irection o" the !evelopment o"
each con!ition.
$ur "in!in6s re6ar!in6 the association bet3een maAor !epressive !isor!er an! lo3 CD,
counts are in 4eepin6 3ith previous stu!ies L1-M1 L,+M1 L+0M. 9hese "in!in6s coul! be
e@plaine! b the "act that late sta6e !isease %mani"este! b lo3 CD, counts& ma have an
aetiolo6ical role in the !evelopment o" !epression amon6 P8?/A. 9he presence o"
!epression in P8?/A coul! also lea! to a !ecline in CD, levels; such an association has
been previousl !ocumente! L1-M1 L+0M. It:s also possible that the sic4er P8?/A become1
the more li4el the are to report smptoms o" maAor !epressive !isor!er. More 3or4 is
nee!e! to e@amine such hpotheses.
9he association bet3een maAor !epressive !isor!er an! oun6er a6e contra!icts previous
stu!ies 3here maAor !epressive !isor!er 3as particularl common in ol!er people
atten!in6 P/C services L3+M1 L3BM1 L+1M. Perhaps the !i""erent conte@ts in 3hich
/I<)AIDS mani"ests coul! e@plain such !i""erences. Speci"ic neurobiolo6ical "actors
ma pla a role in contributin6 to maAor !epressive !isor!er in ol!er subAects; "urther
3or4 is nee!e! to e@plore this hpothesis.
A number o" limitations in this stu! !eserve emphasis. ?e utilise! a cross=sectional
!esi6n1 so that causalit cannot be "ull a!!resse!. A lon6itu!inal "ollo3=up stu! coul!
provi!e better insi6ht into the precise nature o" the relationship bet3een !epression1 an!
the stu!ie! "actors. 9hat sai!1 P8?/A shoul! be assesse! "or both maAor !epressive
!isor!er an! AIDS relate! sti6ma since both con!itions ma present concurrentl in the
same in!ivi!ual.
Secon!l1 the stu! 3as con!ucte! in a sin6le P/C site1 an! ma not be representative o"
the bur!en o" maAor !epressive !isor!er in P8?/A in >6an!a.
9hir!l1 3e !i!n:t abstract in"ormation re6ar!in6 patients bein6 on A591 !espite the "act
that a number o" P8?/A at the stu! site 3ere accessin6 A59. 9his in"ormation coul!
have 6iven us better insi6ht into its relationship 3ith !epression an! sti6ma.
Jourth1 the instruments 3e use! inclu!in6 the MI.I1 AIDS sti6ma scale1 an! the P/E=*
haven:t been vali!ate! in >6an!a. 9his coul! have le! to some inaccuracies in our
"in!in6s. /o3ever1 a number o" stu!ies have been con!ucte! in >6an!a usin6 the MI.I1
an! have reporte! similar prevalence "in!in6s to our stu! L+M1 L*M1 L+2M1 L+3M
Despite these limitations1 this stu! reports on the association bet3een maAor !epression1
AIDS sti6ma an! a number o" variables amon6 P8?/A in sub=Saharan A"rica.
Clinicians 3or4in6 in /I< settin6s shoul! re6ularl assess "or both !epression an!
sti6ma amon6 clinic atten!ees1 since these con!itions ma be present concurrentl in
P8?/A.
In conclusion1 !ue to the hi6h bur!en o" maAor !epressive !isor!er1 an! its association
3ith AIDS relate! sti6ma amon6 P8?/A1 routine screenin6 o" P8?/A "or both
con!itions is recommen!e!. /o3ever1 "urther 3or4 ma be reFuire! to un!erstan! the
comple@ relationships bet3een AIDS sti6ma an! maAor !epressive !isor!er. Jurther 3or4
to !isentan6le the relationships bet3een maAor !epressive !isor!er an! lo3 CD, counts is
eFuall nee!e!.
;o to#
Ac3nowled'ments
Dr A4ena 3as supporte! b the >niversit o" Cape 9o3n %>C9& International Stu!ent:s
Scholarship an! the A"rican Doctoral Dissertation Jello3ship.
;o to#
,undin' Statement
9he stu! receive! "un!in6 "rom the International Stu!ent Scholarship at the >niversit
o" Cape 9o3n%>C9&1 an! the A"rican Doctoral Dissertation 5esearch
Jello3ship%ADD5J&. 9he "un!ers ha! no role in stu! !esi6n1 !ata collection an!
analsis1 !ecision to publish1 or preparation o" the manuscript.
;o to#
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Jurnal )
Sst 5ev. 2012; 1# 30.
Publishe! online 2012 June 2'. !oi# 10.11'B)20,B=,0+3=1=30
PMCID# PMC3,,1*0*
%ental health outcomes in HIV and
childhood maltreatment: a systematic
re-iew
;eor6ina Spies1
1
9racie $ A"i"i1
,
Sarah 8 Archibal!1
+1B
Christine Jennema=.otestine1
+1B

Jiten!er Sareen1
3
an! Soraa See!at
112
Author in"ormation 7 Article notes 7 Copri6ht an! 8icense in"ormation 7
;o to#
Abstract
+ac3'round
/i6h rates o" chil!hoo! maltreatment have been !ocumente! in /I<=positive men an!
3omen. In a!!ition1 mental !isor!ers are hi6hl prevalent in both /I<=in"ecte!
in!ivi!uals an! victims o" chil!hoo! maltreatment. /o3ever1 there is a paucit o"
research investi6atin6 the mental health outcomes associate! 3ith chil!hoo!
maltreatment in the conte@t o" /I< in"ection. 9he present sstematic revie3 assesse!
mental health outcomes in /I<=positive in!ivi!uals 3ho 3ere victims o" chil!hoo!
maltreatment.
%ethods
A sstematic search o" all retrospective1 prospective1 or clinical trial stu!ies assessin6
mental health outcomes associate! 3ith /I< an! chil!hoo! maltreatment. 9he "ollo3in6
online !atabases 3ere searche! on 2+(31 Au6ust 2010# PubMe!1 Social Science Citation
In!e@1 an! the Cochrane 8ibrar %the Cochrane Central 5e6ister o" Controlle! 9rials an!
the Cochrane Developmental1 Pschosocial an! 8earnin6 Problems1 /I<)AIDS1 an!
Depression1 An@iet an! .eurosis re6isters&.
"esults
?e i!enti"ie! 3, stu!ies suitable "or inclusion. A total o" 1,1*3+ participants 3ere
inclu!e! in these stu!ies. A variet o" mi@e! mental health outcomes 3ere reporte!. 9he
most commonl reporte! pschiatric !isor!ers amon6 /I<=positive in!ivi!uals 3ith a
histor o" chil!hoo! maltreatment inclu!e!# substance abuse1 maAor !epressive !isor!er1
an! posttraumatic stress !isor!er. An association bet3een chil!hoo! maltreatment an!
poor a!herence to antiretroviral re6imens 3as also reporte! in some stu!ies.
Conclusion
A broa! ran6e o" a!ult pschopatholo6 has been reporte! in stu!ies o" /I<=in"ecte!
in!ivi!uals 3ith a histor o" chil!hoo! maltreatment. /o3ever1 a !irect causal lin4
cannot be 3ell establishe!. 8on6er term assessment 3ill better !elineate the nature1
severit1 an! temporal relationship o" chil!hoo! maltreatment to mental health outcomes.
Keywords: AIDS1 An@iet1 Chil!hoo! maltreatment1 Depression1 /I<1 Pschiatric
morbi!it1 Substance abuse
;o to#
+ac3'round
Abuse is a common phenomenon in countries 3here the prevalence rate o" /I< is also
hi6h an! can inclu!e phsical1 se@ual an! emotional violence an! !eprivation or ne6lect
L1M. Stu!ies con!ucte! in !evelopin6 countries such as South A"rica an! other A"rican
countries have reporte! hi6h rates o" abuse in both a!ults an! chil!ren. 9his inclu!es
intimate partner violence %IP<&1 rape1 an! chil!hoo! abuse or maltreatment L1=3M.
Chil!hoo! maltreatment has been !e"ine! in man !i""erent 3as. /o3ever1 "or the
present revie31 chil!hoo! maltreatment inclu!e! emotional1 phsical1 an! se@ual abuse
an! emotional an! phsical ne6lect. Accor!in6 to Gernstein et al. L,M se@ual abuse is
!e"ine! as [se@ual contact or con!uct bet3een a chil! oun6er than 1' ears o" a6e an!
an a!ult or ol!er person.V Phsical abuse is !e"ine! as [bo!il assaults on a chil! b an
a!ult or ol!er person that pose! a ris4 o" or resulte! in inAur.V Imotional abuse is !e"ine!
as [verbal assaults on a chil!Vs sense o" 3orth or 3ell=bein6 or an humiliatin6 or
!emeanin6 behaviour !irecte! to3ar! a chil! b an a!ult or ol!er person.V Phsical
ne6lect is !e"ine! as [the "ailure o" careta4ers to provi!e "or a chil!Vs basic phsical
nee!s1 inclu!in6 "oo!1 shelter1 clothin61 sa"et1 an! health care.V Imotional ne6lect is
!e"ine! as [the "ailure o" careta4ers to meet chil!renVs basic emotional an! pscholo6ical
nee!s1 inclu!in6 love1 belon6in61 nurturance1 an! supportV L,M. Althou6h 3omen are more
vulnerable an! re6ar!e! as particularl at ris4 "or abuse1 men are also victims o" rape an!
chil!hoo! maltreatment.
Man stu!ies have investi6ate! the lin4 bet3een a!verse chil!hoo! e@periences such as
phsical an!)or se@ual abuse an! /I< ris4. 9he e@perience o" chil!hoo! maltreatment
ma increase /I< in"ection ris4 in!irectl b increasin6 hi6h=ris4 behaviors or b
inter"erin6 3ith /I< prevention choices L+M. Jor e@ample1 man o" the outcomes
associate! 3ith chil!hoo! maltreatment place in!ivi!uals at increase! ris4 o" contractin6
/I< throu6h behaviors such as transactional se@1 unprotecte! se@1 inabilit to ne6otiate
con!om use1 alcohol an!)or !ru6 abuse1 earl onset o" se@ual activities1 an! multiple se@
partners LB=10M. In a!!ition1 chil!hoo! maltreatment ma !irectl increase the ris4 o" /I<
in"ection throu6h se@ual abuse. InAur an! the tearin6 o" tissue resultin6 "rom se@ual
violence ma increase the li4elihoo! o" /I< in"ection L11M. Stu!ies have also "oun! that
chil!hoo! maltreatment is stron6l associate! 3ith a!ult revictimiKation 3hich can
"urther increase the ris4 "or /I< amon6 3omen L+M.
9he mental health outcomes o" /I<=in"ecte! in!ivi!uals have been 3ell !ocumente! to
!ate. 5esearch su66ests a si6ni"icant bur!en o" mental illness in in!ivi!uals livin6 3ith
/I<)AIDS1 both 6loball an! in the !evelopin6 3orl!. Mental illnesses !ocumente! in
/I<=in"ecte! in!ivi!uals inclu!e pre!ominantl substance use1 an@iet1 an! moo!
!isor!ers L12=1*M. Moreover1 it has been su66este! that /I< !isease pro6ression ma be
hastene! b mental !isor!ers such as !epression an! an@iet L20M.
Similarl1 research su66ests the lon6=term mental health outcomes o" chil!hoo!
maltreatment inclu!e pre!ominantl substance1 an@iet1 an! moo! !isor!ers L21122M.
Interestin6l1 2aplo3 an! ?i!om L23M "ollo3e! ,*B in!ivi!uals 3ith ne6lect1 phsical
an! se@ual abuse prior to the a6e o" 12 into a!ulthoo!. 9heir research su66ests that an
earlier onset o" maltreatment pre!icte! more smptoms o" an@iet an! !epression in
a!ulthoo!1 3hile controllin6 "or 6en!er1 race1 current a6e an! reports o" other abuse.
8ater onset o" maltreatment 3as pre!ictive o" more behavioral problems in a!ulthoo!
L23M. In a revie3 o" chil! se@ual abuse1 Johnson L11M outlines a number o" chil! an! a!ult
pscholo6ical an! behavioral conseFuences o" chil! se@ual abuse. 9hese inclu!e
substance use !isor!ers1 an! an@iet an! moo! !isor!ers1 amon6st others L11M.
Althou6h man stu!ies have "ocuse! on mental health outcomes in chil!hoo!
maltreatment an! /I< separatel1 there is a paucit o" research investi6atin6 chil!hoo!
maltreatment an! /I< in combination1 an! the associate! mental health outcomes in
!uall a""ecte! men an! 3omen. /I<=in"ecte! 3omen ma "ace more current an! past
ne6ative li"e events than men in !evelopin6 parts o" the 3orl! L13M an! this ma lea! to
si6ni"icant a!ult pschopatholo6 an! poor a!herence to antiretroviral me!ications
L2,12+M. In li6ht o" this1 it is evi!ent that /I<=positive in!ivi!uals1 3omen in particular1
are vulnerable to ris4 "actors associate! 3ith abuse1 an! abuse=relate! chan6es in
behavioral "unctionin61 3hich ma complicate /I< in"ection. A sstematic assessment
an! summar o" the available evi!ence is there"ore 3arrante! in or!er to a!! to the
available evi!ence "or both clinical an! research !ecision ma4in6.
;o to#
%ethods
Search strate'y and selection criteria
?e searche! the electronic !atabases PubMe!1 Social Science Citation In!e@1 the
Cochrane 8ibrar %9he Cochrane Central 5e6ister o" Controlle! 9rials# CI.95A8& an!
the Cochrane Developmental1 Pschosocial an! 8earnin6 Problems1 /I<)AIDS1 an!
Depression1 An@iet an! .eurosis re6isters on 2+(30 Au6ust 2010. .o limit on the time
perio! 3as applie! to the search in or!er to avoi! omission o" relevant stu!ies. 5e"erence
lists o" articles i!enti"ie! throu6h !atabase searches an! biblio6raphies o" sstematic an!
non=sstematic revie3 articles 3ere e@amine! to i!enti" "urther relevant stu!ies. ?e
inclu!e! all In6lish lan6ua6e1 ori6inal research %retrospective an! prospective stu!ies&
an! clinical trials reportin6 mental health outcomes o" chil!hoo! trauma in /I<=positive
in!ivi!uals. 9he population inclu!e! a!ult men an! 3omen alrea! in"ecte! 3ith
/I<)AIDS 3ho e@perience! chil!hoo! maltreatment prior to 1' ears o" a6e. ?e
e@clu!e! sstematic an! non=sstematic revie3 articles an! stu!ies o" no !irect relevance
to the comprehensive search. 9he PubMe! search inclu!e! the "ollo3in6 terms#
chil!hoo! abuse A.D /I<. 9he "ull search !etails are as "ollo3s# %%[chil!hoo!VLJournalM
$5 [chil!hoo!VLAll Jiel!sM& A.D %[substance=relate! !isor!ersVLMeS/ 9ermsM $5
%[substance=relate!VLAll Jiel!sM A.D [!isor!ersVLAll Jiel!sM& $5 [substance=relate!
!isor!ersVLAll Jiel!sM $5 [abuseVLAll Jiel!sM&& A.D %[hivVLMeS/ 9ermsM $5 [hivVLAll
Jiel!sM&. .o "ilters 3ere inclu!e! to ensure that all relevant papers 3ere retrieve!. 9he
PubMe! search selecte! those stu!ies that a!!resse! chil!hoo! abuse an! /I< in all
"iel!s. An initial search o" titles 3as un!erta4en b the revie3er %;S&. Stu!ies 3ere
inclu!e! irrespective o" sample siKe an! perio! o" "ollo3=up. 9itles an! abstracts o"
stu!ies that appeare! relevant 3ere then assesse! to !etermine 3hether the met the
inclusion criteria. Abstracts that !i! not meet the inclusion criteria 3ere reAecte!. 9he
revie3er assesse! "ull te@ts o" articles that appeare! to meet the inclusion criteria o" the
present stu!. In"ormation 3as e@tracte! re6ar!in6 population characteristics an! sample
siKe1 stu! !esi6n1 outcomes measure! an! results. .o e@ploration o" publication bias
3as un!erta4en an! it 3as not possible to con!uct a sensitivit analsis "or the current
revie3 article !ue to the "act that no meta=analses 3ere con!ucte! %see Ji6ure
Ji6ure1 1&.
Ji6ure 1
Jlo3 !ia6ram o" revie3 process.
;o to#
"esults
All !atabases searche! iel!e! abstracts1 an! there 3ere !uplicates bet3een the
!atabases. All the stu!ies ha! publishe! results in peer=revie3e! Aournals. 93o hun!re!
an! "ive abstracts 3ere i!enti"ie! an! revie3e!. $" the 20+ abstracts i!enti"ie!1 1-1
articles 3ere e@clu!e!. Stu!ies 3ere e@clu!e! i" the 3ere# o" no relevance to the present
revie31 sstematic or non=sstematic revie3 articles1 or not con!ucte! in the population
o" interest. 9itles an! abstracts o" +2 stu!ies that appeare! relevant 3ere then assesse! to
!etermine 3hether the met the inclusion criteria. $" the relevant stu!ies revie3e!1 3,
articles met inclusion criteria. 9hree o" the 3, articles 3ere source! "rom re"erence lists
o" other manuscripts. Jull te@t articles "or all 3, stu!ies 3ere accesse! an! revie3e!. 9he
revie3e! articles are summariKe! in 9able 9able1. 1. 9here 3as hetero6eneit in sample
characteristics1 stu! metho!olo6ies an! outcome measures amon6 all stu!ies revie3e!
in this article. Moreover1 some stu!ies inclu!e! an /I< comparison 6roup 3hereas others
!i! not1 "urther limitin6 comparabilit. Jor these reasons1 it 3as !eci!e! that a meta=
analsis o" these !ata 3as not "easible. <ariabilit in measurement o" mental health
impairment 3as note!. Pschiatric smptoms an! !isor!ers 3ere assesse! accor!in6 to
stan!ar! !ia6nostic criteria1 usin6 a structure! clinician a!ministere! intervie3 an!)or
throu6h sel"=report %see 9able 9able1&. 1&. Althou6h some stu!ies !i""erentiate! smptoms
an! !ia6noses1 others reporte! more 6lobal levels o" pscholo6ical !istress. Jor e@ample1
t3o articles source! reporte! on 6lobal pscholo6ical !istress an! mental health in
6eneral1 3ithout !elineatin6 3hether smptoms 3ere !epressive in nature or an@iet
relate!1 "or e@ample L2B12-M. Jurthermore1 some stu!ies simpl state! the percenta6e o"
/I<=positive maltreatment victims reportin6 smptoms o" an@iet. Althou6h these stu!ies
reporte! 6lobal an@iet levels1 the "aile! to !i""erentiate b !ia6nosis L-12'=30M.
9able 1
Summar o" 3, articles selecte! "or revie3
A histor o" chil!hoo! maltreatment 3as also assesse! in !i""erent 3as1 but all stu!ies
relie! on sel"=reporte! histor o" chil!hoo! maltreatment1 an! most assessments 3ere
retrospective in nature. In some stu!ies1 chil!hoo! maltreatment inclu!e! various
"orms)tpes such as phsical abuse an! ne6lect1 emotional abuse an! ne6lect1 an! se@ual
abuse L,3M. $ther stu!ies onl e@amine! chil!hoo! se@ual abuse %CSA& LB12B1,0M or
combine! se@ual an! phsical abuse into one cate6or o" chil! abuse L2+13*1,1M. Some
stu!ies utiliKe! vali!ate! sel"=report measures sensitive in tappin6 into various "orms o"
chil!hoo! abuse an! ne6lect L3'1,3M. A 3i!el use! e@ample o" such a measure is the
Chil!hoo! 9rauma Euestionnaire L,M. /o3ever1 man stu!ies establishe! a histor o"
chil!hoo! abuse b simpl as4in6 a sin6le Fuestion such as [have ou ever e@perience! a
se@ual assault or rape as a chil! or teena6er1 that is1 3hen ou 3ere 1' ears o" a6e or
oun6erYV an! usin6 a !ichotomous response option %0es).o& L2B12'1,2M.
Childhood maltreatment
Chil!hoo! maltreatment1 such as phsical an! se@ual abuse is a common phenomenon in
the 6eneral population %unin"ecte! in!ivi!uals&. CSA is reporte! b as man as 32C o"
3omen an! 1,C o" men in the 6eneral population1 3hereas phsical abuse is e@perience!
b 22C o" males an! 1*.+C o" "emales in the 6eneral population L++M. /o3ever1 rates o"
chil!hoo! maltreatment in /I<=positive in!ivi!uals are si6ni"icantl hi6her1 su66estin6
that the e@perience o" chil!hoo! maltreatment in the conte@t o" /I< is 3orth o" 6reater
attention. 5ates o" CSA amon6 /I<=positive in!ivi!uals ran6e "rom 32C to -BC1
respectivel L2'1+B1+-M.
%ental health outcomes
In revie3in6 the articles1 a 3i!e ran6e o" mental health smptoms an! !isor!ers 3ere
reporte!. 9he most commonl reporte! pschiatric smptomatolo6 amon6 /I<=positive
in!ivi!uals 3ith a histor o" chil!hoo! maltreatment inclu!e! %stu! number in 9able
9able1&# 1&# !ru6 an!)or alcohol abuse)!epen!ence %21,1-1*=1-120=2,12B=33&1 !epression
%21,1B1*11011311+11-120=2B12'& an! posttraumatic stress !isor!er %P9SD& %113=+1'11211'=
2012312,12B130&. $ther mental health outcomes reporte! inclu!e! %re"erence number in
9able 9able1&# 1&# an@iet %,11B122=2,12B12'&1 6eneraliKe! an@iet !isor!er %20&1
bor!erline personalit %1B133&1 panic !isor!er %2112B&1 a6oraphobia %2B&1 schiKophrenia
%21&1 pschotic !isor!er %22&1 a!Austment !isor!er %22&1 bipolar !isor!er %22&1 suici!alit
%*121&1 neuroticism %*&1 personalit !isor!er %,& an! multiple personalit !isor!er %21&.
Moreover1 3hen e@aminin6 mental health outcomes such as !ru6 abuse an! !epressive
smptomatolo61 t3o articles also reporte! an association bet3een chil!hoo!
maltreatment an! poor treatment a!herence to antiretroviral re6imens %1311-&. Phsical
complaints)!istress an! re!uce! Fualit o" li"e 3as also a "in!in6 in the stu!ies revie3e!
%1,11'12B&. Jin!in6s "rom several stu!ies in!icate! that participants ha! at some time in
their lives un!er6one mental health treatment %2212B12-12*133&. Man stu!ies "oun!
participants commonl reportin6 en6a6ement in hi6h=ris4 behaviors such as transactional
se@ or compulsive se@ual behaviors %1011111+121130=32& an! a!ult revictimiKation 3as
common %31,11012,12B12-131&. In!ivi!ual rates o" pschopatholo6 reporte! in stu!ies
varie!. 9he percenta6e o" participants in in!ivi!ual stu!ies 3ho receive! a !ia6nosis o"
P9SD inclu!e! %stu! number in 9able 9able1&# 1&# ,2.*C %1&1 ,0C %3&1 32C %,&1 ,0C
%+&1 3+C %1'&1 ,2C %1*&1 2'C %20& an! 1BC %23&. $ther stu!ies reporte! P9SD scores on
sel"=report)intervie3er a!ministere! instruments. 9he avera6e P9SD score on the
Posttraumatic Dia6nostic Scale 3as 20.-+ in one stu!1 3ith 30C o" participants
reportin6 mo!erate to severe smptoms an! 1+C reportin6 severe smptoms %12&. In
another stu!1 the mean score on the 9rauma Smptom Inventor "or trauma=relate!
smptoms 3as ,0., in 3omen an! 2'.* in men %2,&. P9SD 3as not an inclusion criterion
in the research stu! but rather an unselecte! observation "or most stu!ies
%1131+11212012312,&. /o3ever1 in one stu!1 participants 3ere onl inclu!e! i" there 3as
evi!ence o" pscholo6ical !istress or i" criteria "or moo! or an@iet !isor!ers 3ere met
%,&.
9he percenta6e o" participants in in!ivi!ual stu!ies 3ho receive! a !ia6nosis o" moo!
!isor!ers inclu!e! %stu! number in 9able 9able1&# 1&# ,B.,C %,& B'C %10&1 1+C %20&1
30C %22&1 3,.-C %23& an! 3*C %2'&. $ther stu!ies reporte! !epression scores on sel"=
report)intervie3er a!ministere! instruments. 9he mean !epression score on the Center "or
Ipi!emiolo6ic Stu!ies Depression Scale %CIS=D& 3as 23 in one stu! %B& an! in another
stu!1 '1C o" 3omen an! -BC o" men ha! a !epression score hi6her than 1B on the CIS=
D %1-&. 9he mean score "or !epressive smptoms on the Gec4 Depression Inventor 3as
2*.' in 3omen an! 2'.2 in men in another stu! %2,&. Moo! !isor!ers 3as not an
inclusion criterion in the research stu! but rather an unselecte! observation "or most
stu!ies %2012312,12'&. /o3ever1 in other stu!ies1 participants 3ere onl inclu!e! i" there
3as evi!ence o" pscholo6ical !istress or criteria "or moo! or an@iet !isor!ers 3ere met
%,122&.
9he percenta6e o" participants in in!ivi!ual stu!ies 3ho receive! a !ia6nosis o" !ru6
an!)or alcohol !epen!ence)abuse inclu!e! %stu! number in 9able 9able1&# 1&# 2+C %,&1
+'C li"etime an! *C current %-& --C %*&1 ''C %10&1 ++C %1,&1 1*C an! 31C %20&1 3-C
an! 10C %22&1 20C %23&1 31.'C1 +3.2C1 1'.2C1 3B.3C1 33.1C an! 1'.*C %2,&1 3'.3C
%2-&1 2'C %2*& an! 2'C %33&. $ther stu!ies !i! not report in!ivi!ual rates but su66este!
that abuse! /I<=positive in!ivi!uals 3ere more li4el to have en6a6e! in alcohol or !ru6
abuse an! receive! treatment "or substance abuse %2111=1311+=1-12112B12'130=32&. Dru6
an!)or alcohol !epen!ence)abuse 3as not an inclusion criteria in the research stu! but
rather an unselecte! observation "or most stu!ies %21,1-111=1B120=2,12B=33&. /o3ever1 in
other stu!ies1 participants 3ere onl inclu!e! i" there 3as evi!ence o" !ru6 an!)or
alcohol !epen!ence)abuse %*11-&.
In comparison to the 6eneral population %i.e. unin"ecte! an! non=abuse! counterparts&1
evi!ence su66ests that on6oin6 ris4 behaviors an! rates o" pschopatholo6 are hi6her in
/I<=in"ecte! in!ivi!uals 3ith histories o" abuse L-1'11013113-1+3M. /I<=positive
in!ivi!uals 3ere more li4el to report posttraumatic stress1 ris4 health behaviors1
substance abuse1 chronic stress1 an! pschiatric histor compare! 3ith /I<=ne6ative
counterparts L+3M. In a!!ition1 abuse! in!ivi!uals reporte! hi6her rates o" mental illness1
compare! to non=abuse! counterparts1 su66estin6 that a histor o" abuse in chil!hoo!
increases the li4elihoo! o" pschopatholo6 L+'M. 9hese "in!in6s len! cre!ence to the
ar6ument that chil!hoo! maltreatment in the conte@t o" /I< is 3orth o" 6reater
attention.
Inter-ention studies
9he revie3 reveale! si@ intervention stu!ies that have been con!ucte! 3ith this
population L'131=3+M. 9hree o" these interventions 3ere carrie! out in bise@ual men an!
men 3ho have se@ 3ith men %MSM& L'13113+M an! three 3ere carrie! out in mi@e!
samples o" males an! "emales L32=3,M. A total o" ,2*+ MSM 3ere enrolle! into a
behavioral intervention trial over ,' months. Gehavioral assessments 3ere con!ucte!
ever B months. /o3ever1 the results reveale! that amon6 men reportin6 a histor o"
CSA1 the intervention ha! no e""ect in re!ucin6 /I< in"ection rates. Moreover1 men
reportin6 a histor o" CSA 3ere more li4el to !ispla !epressive smptomatolo6 an!
use nonprescription !ru6s L'M. Similarl1 ,* 6a an! bise@ual /I<=in"ecte! men 3ith
histories o" CSA 3ere enrolle! into an intervention stu!1 consistin6 o" 1+ copin6 6roup
sessions. ?hen compare! to an alternative support 6roup intervention an! a control
con!ition1 the copin6 6roup intervention prove! to be e""icacious in treatin6 /I<=positive
a!ults 3ith histories o" CSA. 9his 3as attributable to the inclusion o" a copin6 s4ills
trainin6 component in the a"orementione! treatment con!ition L31M. Support "or the
e""icac o" the a"orementione! copin6 6roup intervention 3as reporte! in a separate stu!
assessin6 2' men an! 3omen 3ith /I< an! histories o" CSA L33M. Similarl "in!in6s
3ere reporte! in another stu! utiliKin6 the same copin6 6roup intervention in 1*' /I<=
in"ecte! men an! 3omen 3ith histories o" CSA L3,M. 5e!uctions in intrusive traumatic
stress smptoms 3ere e@hibite! amon6 participants in the copin6 6roup intervention
compare! to the 3aitlist con!ition an! in avoi!ant traumatic stress smptoms compare!
to the support 6roup con!ition L3,M. Moreover1 the e""icac o" the a"orementione! copin6
6roup intervention in re!ucin6 se@ual transmission ris4 behavior 3as assesse! L32M. 9he
se@ual behavior o" 2,- /I<=positive men an! 3omen 3ith histories o" CSA 3as assesse!
at baseline1 postintervention1 an! at ,1 '1 an! 12 month "ollo3=up perio!s. 9he "reFuenc
o" unprotecte! se@ual intercourse "or all partners !ecrease! more amon6 participants in
the copin6 6roup intervention than participants in the support intervention con!ition L32M.
8astl1 a ran!omiKe! clinical trial comparin6 the e""ects o" t3o si@=session interventions
3as carrie! out in a sample o" 13- bise@ual men an! MSM. 5esults "rom both
interventions reveale! re!uctions in se@ual ris4 behaviors an! number o" se@ual partners
"rom baseline to posttest1 an! "rom 3 to B month "ollo3=ups. .o si6ni"icant !i""erences in
!epression 3ere evi!ent bet3een the t3o con!itions; ho3ever1 at B months the total
sample reporte! a si6ni"icant !ecrease in !epressive smptoms L3+M.
Adherence to antiretro-iral medication
In e@aminin6 mental health outcomes1 t3o articles also reporte! an association bet3een
chil!hoo! maltreatment an! poor treatment a!herence to antiretroviral re6imens L2+1,3M.
In one stu!1 a lo3er percenta6e o" 3omen 3ith a histor o" phsical or se@ual abuse
reporte! usin6 /i6hl Active Antiretroviral 9herapies %/AA59&. I@periencin6 an
phsical or se@ual abuse increase! the li4elihoo! o" no /AA59 use. ?omen 3ith a
histor o" an phsical or se@ual abuse 3ere more than 1.+ times more li4el to lac4
/AA591 even 3hen clinicall eli6ible L2+M. Moreover1 the use o" /I< me!ications has
been "oun! to be ne6ativel associate! 3ith CSA e@periences L,3M.
Hi'h ris3 beha-iors
Man stu!ies "oun! participants commonl reportin6 en6a6ement in hi6h=ris4 behaviors
such as transactional se@ or compulsive se@ual behaviors L31B13*1,01,21+3M. In!ivi!uals
3ho e@perience! abuse re6ularl 3ere more li4el to be /I<=positive1 e@chan6e! se@ "or
pament1 an! be a current user o" se@=relate! !ru6s L,0M. It has also been reporte! that
3omen e@periencin6 CSA 3ere more li4el than 3omen 3ithout such histories to have
use! !ru6s1 to have ha! more than ten se@ual partners1 to have tra!e! se@ "or mone1
!ru6s1 or shelter; an! to have been "orce! to have se@ 3ith a person 4no3n to be /I<=
positive LBM. Moreover1 3omen 3ho ha! been se@uall assaulte! 3ere si6ni"icantl more
li4el to have share! inAection !ru6 eFuipment L3M.
;o to#
Discussion
?e per"orme! a comprehensive sstematic revie3 o" the literature to assess mental health
outcomes in /I<=positive in!ivi!uals 3ith histories o" chil!hoo! maltreatment. 9o our
4no3le!6e1 this is the "irst revie3 o" its 4in!; no publishe! sstematic revie3s assessin6
this association have been con!ucte! to !ate.
9he reporte! mental health outcomes in !uall a""ecte! in!ivi!uals %/I<=positive
in!ivi!uals 3ith histories o" chil!hoo! maltreatment& are in 4eepin6 3ith stu!ies that
have investi6ate! these variables separatel L11=1*123M1 supportin6 at least common
outcomes1 althou6h assessment o" the a!!itive e""ects o" /I< an! chil!hoo! trauma is
!i""icult in this retrospective revie3.
9he most commonl reporte! mental illnesses in !uall a""ecte! in!ivi!uals inclu!e!
moo!1 an@iet1 an! substance abuse !isor!ers. <er "e3 stu!ies e@amine! A@is II
!isor!ers. It has been su66este! that an /I< !ia6nosis alone ma constitute a si6ni"icant
stressor an! thus increase the li4elihoo! o" mental illnesses amon6 /I<=positive
in!ivi!uals L+*M. Apart "rom !epression or an@iet bein6 a secon!ar !ia6nosis to
/I<)AIDS1 an@iet an! !epressive smptoms measure! over time 3ere also associate!
3ith "aster pro6ression o" the !isease a"ter "ive ears. 9his "in!in6 ma su66est a
rein"orcin6 relationship bet3een /I< an! mental illnesses such as !epression or an@iet
L20M. /o3ever1 the maAorit o" stu!ies revie3e! 3ere cross=sectional in nature1 there"ore
limitin6 their abilit to ma4e causal conclusions aroun! the onset o" mental illness in
/I<. 9his hi6hli6hts the importance o" lon6er term assessment in or!er to better !elineate
the nature1 severit1 an! temporal nature o" mental health outcomes. Importantl1 mental
!isor!ers such as !epression or an@iet can "urther impact immune sstem "unctionin6 in
/I< an!1 in turn1 in"luence Fualit o" li"e an! health status LB0M.
Substance abuse 3as the most pre!ominant mental health outcome reporte! in revie3e!
articles. Jor the most part1 !ru6s an!)or alcohol are use! to numb emotional !istress an!
"eelin6s o" an6er an! betraal resultin6 "rom the e@perience o" chil!hoo! maltreatment
L+0M. .ot onl !oes substance abuse have !irect implications "or the pro6ression o" the
!isease in in"ecte! in!ivi!uals LB1M1 it also has !irect an! in!irect implications "or the
transmission o" /I<. Antiretroviral re6imens are 4no3n to have stron6 positive e""ects on
Fualit o" li"e an! in improvin6 health status in in"ecte! in!ivi!uals LB2M. Je3 articles
have reporte! an association bet3een chil!hoo! maltreatment an! poor treatment
a!herence to antiretroviral re6imens or /I< me!ications L2+1,3M.
Some stu!ies that investi6ate! both earl li"e trauma an! a!ult trauma "oun! an
association bet3een chil!hoo! trauma an! later li"e trauma LB12'13213-M. Jor e@ample1
the stu! b Simoni an! .6 "oun! that chil!hoo! abuse 3as correlate! 3ith both a!ult
an! recent trauma. Moreover1 each tpe o" trauma 3as also correlate! 3ith !epression
scores L,*M. Several stu!ies have also "oun! that a!ult revictimiKation 3as ver common
in survivors o" chil!hoo! maltreatment LB13213313*1+01+1M. Jurther investi6ation o" this
relationship an! the implications "or prevention an! intervention is 3arrante!.
/I<=in"ecte! men an! 3omen ma "ace man current an! past ne6ative li"e events L13M
an! this ma lea! to si6ni"icant a!ult pschopatholo6 an! poor a!herence to
antiretroviral me!ications L2,12+1B3M. In li6ht o" this1 it is evi!ent that /I<=positive
in!ivi!uals1 3omen in particular1 are vulnerable to ris4 "actors associate! 3ith abuse1 an!
abuse=relate! chan6es in behavioral "unctionin6. 9hese ris4 "actors an! behavioral
chan6es ma in turn complicate /I< in"ection.
9here are several limitations that 3arrant mention. Jirst1 no search strate6 can 6uarantee
the i!enti"ication o" all relevant research1 an! omission o" important stu!ies remains a
possibilit an! ma contribute to bias in in"erences !ra3n. Selection or revie3er bias
ma be a possibilit 6iven that stu!ies 3ere not screene! or abstracte! in !uplicate.
Secon!1 the hetero6eneit across stu!ies presents a problem as it impe!es statistical
poolin6 o" stu!ies. 9hir!1 it is important to note the controvers that aboun!s in the
classi"ication o" search terms. 9here is no stan!ar! !e"inition "or the e@perience o" abuse
as a chil!. 9his construct is one that is classi"ie! an! assesse! in a variet o" 3as. Some
stu!ies use broa!er terms such as chil!hoo! a!versit or maltreatment1 3hereas others
use more speci"ic terms such as chil! abuse. Jor e@ample1 in some stu!ies revie3e!1
chil!hoo! maltreatment inclu!e! !iverse tpes o" trauma such as phsical abuse an!
ne6lect1 emotional abuse an! ne6lect1 an! se@ual abuse. $ther stu!ies have use! more
restricte! !e"initions an! have onl e@amine! CSA or resorte! to combinin6 se@ual an!
phsical abuse into one cate6or o" chil! abuse. Chil!hoo! maltreatment in the present
revie3 inclu!e! emotional1 phsical1 an! se@ual abuse an! ne6lect. 9he lac4 o" a stan!ar!
!e"inition is a "urther source o" bias. Another limitation that 3arrants mention is that o"
the !esi6n o" the revie3 process. 9he selection criterion "or the inclusion o" stu!ies in the
present revie3 3as manuscripts reportin6 on mental health an! chil!hoo! maltreatment.
/o3ever1 this shoul! not be mista4en or presente! as an ar6ument that chil!hoo!
maltreatment an! impairments in mental health are associate!. /o3ever1 !espite these
limitations1 this revie3 a!!s substantiall to available evi!ence "or both clinical an!
research !ecision ma4in6.
Implications for future studies
Jrom the present revie31 it is clear that ver "e3 prospective stu!ies have been e@ecute!
in this !omain L311,,M. 9he maAorit o" research has been cross=sectional an! has
inclu!e! retrospective assessment o" chil!hoo! maltreatment in /I<=in"ecte! in!ivi!uals.
9his ma be partl !ue to reasons associate! 3ith "easibilit an! lo6istics. As cross=
sectional stu! !esi6ns preclu!e "ollo3=up observations an! lon6er term assessment o"
outcomes1 "uture research shoul! be prospective in nature an! shoul! better !elineate the
nature1 severit1 an! temporal relationship o" chil!hoo! maltreatment to mental health
outcomes an! treatment utiliKation1 as 3ell as the me!iators an! mo!erators o" these
outcomes. 9hese stu!ies 3ill allo3 both clinicians an! researchers to better un!erstan!
the etiolo6 o" common mental !isor!ers in /I<=in"ecte! samples an! re!uce bias 3hen
ma4in6 causal in"erences. 9hus1 lon6itu!inal investi6ation o" mental health outcomes in
/I< in"ecte! in!ivi!uals 3ith chil!hoo! maltreatment 3ill be 4e to e@plainin6 these
causal relationships.
;o to#
Conclusion
A broa! ran6e o" a!ult pschopatholo6 has been reporte! in stu!ies o" /I<=in"ecte!
in!ivi!uals 3ith a histor o" chil!hoo! maltreatment. /o3ever1 a !irect causal lin4
cannot be 3ell establishe!. 9he lon6er term assessment 3ill better !elineate the nature1
severit1 an! temporal relationship o" chil!hoo! maltreatment to mental health outcomes.
9here is a nee! to screen "or chil!hoo! maltreatment1 pschopatholo61 an! associate!
"unctionin6 in /I<=positive in!ivi!uals an! to a!!ress these issues in mana6ement.
Increase! "ocus on the i!enti"ication an! support "or chil!ren an! outh 3ho have
e@perience! chil!hoo! maltreatment is necessar. /I< prevention interventions such as
e!ucation in hi6h=ris4 behaviors are also a necessit.
;o to#
Competin' interests
?e !eclare that 3e have no con"licts o" interests.
;o to#
AuthorsC contributions
;S per"orme! the sstematic revie3 an! !ra"te! the manuscript. 9A1 SA1 CJ=.1 JS1 an!
SS participate! in its !esi6n an! coor!ination an! helpe! to !ra"t the manuscript. All
authors rea! an! approve! the "inal manuscript.
;o to#
Ac3nowled'ements
9his 3or4 is base! upon research supporte! b the South A"rican 5esearch Chairs
Initiative o" the Department o" Science an! 9echnolo6 an! .ational 5esearch
Joun!ation; the M5C >nit on An@iet an! Stress Disor!ers1 Department o" Pschiatr1
>niversit o" Stellenbosch1 Cape 9o3n1 South A"rica; the Clau!e 8eon Joun!ation; the
/en!ri4 <rou3es Scholarship; the Centers "or AIDS 5esearch %CJA5&; an! the /I<
.eurobehavioral 5esearch Center %/.5C; .ational Institute o" Mental /ealth P30=
M/B2+12&.
;o to#
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Jurnal *
AI,. Eehav. 2012 -ovember; 1A%H'" 211*)21$&.
Published online 2012 Ma# &0. doi" 10.100(+s10$A1<012<0212<&
PMCI," PMC&$H10//
!he Impact of DS%-IV %ental Disorders
on Adherence to Combination
Antiretro-iral !herapy Amon' Adult
Persons (i-in' with HIV1AIDS: A
Systematic "e-iew
.andra A. .prin6er1 A?em ,ushaP1 and Mar=an M. A?ar
Author in!ormation : Cop#ri6ht and 8icense in!ormation :
This article has been cited b# other articles in PMC.
0o to"
Abstract
9his is a sstematic revie3 o" ei6ht=t3o publishe! stu!ies investi6atin6 the impact o"
DSM=I< mental !isor!ers on combination antiretroviral therap %cA59& a!herence an!
persistence amon6 persons livin6 3ith /I<)AIDS %P8?/A&. Si@t=t3o articles
e@amine! !epression1 3ith +' C %* D 32)B2& "in!in6 lo3er cA59 a!herence an!
persistence. Seventeen articles e@amine! one or more an@iet !isor!ers1 3ith the maAorit
"in!in6 no association 3ith cA59 a!herence or persistence. Ii6ht percent o" the stu!ies
that evaluate! the impact o" pschotic %* D 3&1 bipolar %* D +& an! personalit !isor!ers
%* D 2& on cA59 a!herence an! persistence also "oun! no association. Seven out o" the
nine stu!ies %-' C& evaluatin6 the impact o" anti!epressant treatment %AD9& on cA59
a!herence "oun! improvement. A!herence an! !epression measurements varie!
si6ni"icantl in stu!ies; common research measurements 3oul! improve !ata
harmoniKation. More research speci"icall a!!ressin6 the impact o" other mental
!isor!ers besi!es !epression on cA59 a!herence an! 5C9s evaluatin6 AD9 on cA59
a!herence are also nee!e!.
&lectronic supplementary material
9he online version o" this article %!oi#10.100-)s10,B1=012=0212=3& contains
supplementar material1 3hich is available to authoriKe! users.
Keywords: HIV+AI,.1 Mental illness1 Adherence1 Antiretroviral therap#1
.#stematic revie=1 Persistence1 cA3T1 ,epression1 An4iet#1 Ps#chotic
disorders
0o to"
Introduction
Combination antiretroviral therap %cA59& has 6reatl improve! the morbi!it1 an!
!ecrease! the mortalit associate! 3ith /I< in"ection L1(3M. 9he bene"its o" cA591
ho3ever1 are tpicall contin6ent upon e@cellent cA59 a!herence an! persistence in
or!er to achieve suppression o" /I<=1 5.A levels an! an increase in CD, 9 cell
lmphoctes L,1 +M. Suboptimal a!herence to cA59 is stron6l relate! to viral
proli"eration LB1 -M1 !ru6 resistance L-1 'M1 !isease pro6ression L*M1 an! !eath L3M. Jactors
that can impair a!herence to cA59 inclu!e !ru6 a!!iction L10(12M1 alcohol use !isor!ers
L111 13M1 lo3 socioeconomic status L1,M1 social sti6ma L1+(1-M1 neuroco6nitive !isor!ers
L1'M1 an! mental !isor!ers L1*M. ?hen combine!1 mental !isor!ers an! substance use
!isor!ers amon6 persons livin6 3ith /I<)AIDS %P8?/A& sner6isticall increase
mortalit via impairin6 a!herence to cA59 L20M.
Mental !isor!ers inclu!e a variet o" pschiatric con!itions an! are !e"ine! b the "ourth
Dia6nostic Manual o" Mental Disor!ers %DSM=I<& L21M as [a clinicall
si6ni"icant behavioral or pscholo6ical impairment o" an in!ivi!ualVs normal co6nitive1
emotional1 or behavioral "unctionin6 associate! 3ith present !istress an! cause! b
phsiolo6ical or pschosocial "actorsV. Mental !isor!ers are more common amon6
P8?/A %B3 C& as compare! to the /I<=ne6ative population %30.+ C& L1*1 22M. In a
recentl publishe! stu!1 /I<=positive men 3ere more li4el to have an moo! !isor!er
Lo!!s ratio %$5& D B.10M1 maAor !epressive !isor!er)!sthmia %$5 D 3.--&1 an an@iet
!isor!er %$5 D ,.02&1 an! an personalit !isor!er %$5 D 2.+0& 3hen compare! to their
/I<=ne6ative same=se@ counterparts L23M. In another stu! an estimate! B0 C o" P8?/A
receivin6 care in .orth Carolina ha! co=morbi! mental !isor!er smptoms L2,M.
9he mental !isor!er most commonl associate! 3ith /I< in"ection is maAor !epressive
!isor!er %MDD& L2+M 3ith a prevalence ran6in6 "rom 1B.2 C L2BM to 3B C L2+M. 9his is a
"our= to seven="ol! 6reater prevalence than in the 6eneral population %,.* C& L2-M. 9he
lar6e variation in prevalence rates o" mental !isor!ers has been partiall attribute! to
!i""erences in the speci"icit an! sensitivit o" the stu! instruments use! L2'M. Mental
!isor!ers have been associate! 3ith !ecrease! a!herence to cA59 an! impaire! /I<
virolo6ic control in several stu!ies L1,1 2*(3BM. In one lon6itu!inal stu!1 /I<=positive
mothers 3ith co=morbi! mental !isor!ers 3ere appro@imatel si@ times more li4el to !ie
than a!herent participants 3ith no !epressive smptoms L32M. A recentl publishe! meta=
analsis o" *+ in!epen!ent stu!ies o" P8?/A 3ith !epressive !isor!ers conclu!e! that
!epression 3as si6ni"icantl associate! 3ith nona!herence to cA59 %r D 0.1*; *+ C
CI D 0.1,(0.2+1 p R 0.0001& L3-M. 9his meta=analsis1 ho3ever1 3as not a sstematic
revie3 o" the stu!ies o" !epression an! a!herence to cA59. 9o the authorsV 4no3le!6e
there has not et been a sstematic revie3 o" stu!ies publishe! in the In6lish literature
evaluatin6 all maAor A@is I an! II DSM=I< mental !isor!ers on cA59 a!herence an!
persistence amon6 a!ult P8?/A.
9he speci"ic aim o" this paper is to there"ore sstematicall revie3 stu!ies evaluatin6 the
impact o" all o" maAor A@is I an! II DSM=I< mental !isor!ers1 e@clu!in6 substance use
!isor!ers1 on combination antiretroviral a!herence an! persistence amon6 P8?/A.
9hou6h maAor !epression is the principal "ocus o" this revie3 !ue to its hi6her
prevalence1 other mental !isor!ers such as an@iet an! pschotic !isor!ers 3ill also be
e@amine! as the have also been reporte! to ne6ativel impact participant a!herence L3,1
3'M.
0o to"
%ethods
Data Search
PubMe!1 Scopus an! ?eb o" 2no3le!6e 3ere Fuerie! "or peer=revie3e! ori6inal human
research papers publishe! in In6lish "rom 1**B to December 2011. ;oo6le Scholar 3as
also revie3e! "or !etails1 "ull te@t1 an! a!!itional articles. 9he search "or this sstematic
revie3 too4 place "rom .ovember 2010 to December 2011. 2e3or!s an! their
combinations use! in the search are available in an on=line appen!i@. Papers 3ere
inclu!e! i" the 3ere con!ucte! in other countries outsi!e o" the >nite! States1 6iven the
hi6h prevalence o" mental !isor!ers amon6 P8?/A throu6hout the 3orl!.
Study Selection and Inclusion1&/clusion Criteria
Ji6ure 1 represents a P5ISMA %Pre"erre! 5eportin6 Items "or Sstematic revie3s an!
Meta=Analses& "lo3 !ia6ram "or this sstematic revie3 L3*M. 9he ori6inal search
resulte! in ,1302 total !ocuments %PubMe!i211+1 articles1 Scopusi11',- articles1 ?eb
o" 2no3le!6ei30, articles& o" 3hich 21B-B articles remaine! a"ter eliminatin6 !uplicate
articles. $" these1 B+* articles met the "ollo3in6 inclusion criteria "or the primar
selection# L1M mental !isor!ers1 inclu!in6 pschotic1 moo!1 an@iet1 somato"orm1 an!
personalit !isor!ers as !e"ine! b International Classi"ication o" Diseases %ICD=* an!
ICD=10& L,01 ,1M1 Dia6nostic an! Statistical Manual o" Mental Disor!ers %DSM=I< A@is I
or II !ia6nosis& L21M or mental health smptoms %man stu!ies use! screenin6 tools "or
mental !isor!er smptoms1 rather than speci"ic mental !isor!er !ia6nostic measures&
L,2M&; an! L2M antiretroviral treatment a!herence or persistence. Articles inclu!e! in this
sstematic revie3 evaluate! the impact o" DSM=I< mental !isor!ers or mental health
smptoms on at least one o" the "ollo3in6 cA59 me!ication terms# %a& A!herence
%snonm# compliance&1 !e"ine! as Othe e@tent to 3hich a participant acts in accor!ance
3ith the prescribe! interval1 an! !ose o" a !osin6 re6imenP or Opercenta6e o" correctl
time! !oses %!oses ta4en)!oses prescribe! j 100&P L,3M an! %b& persistence1 !e"ine! as
Othe !uration o" time o" initiation to !iscontinuation o" therap %b the participant&P L,3M.
;i6. 1
.#stematic revie= stud# selection @o= dia6ram
$ne revie3er %AD& i!enti"ie! the papers inclu!e! in the tables provi!e! 3ithin this
manuscript an! in the electronic appen!i@. A secon! in!epen!ent revie3er %MA& applie!
selection criteria to a ran!om sample consistin6 o" 20 C o" articles "rom the primar
selection. A6reement bet3een revie3ers 3as assesse! usin6 CohenVs 4appa %k& statistic
an! 3as eFual to 0.B* L,,M. ?here there 3ere !i""erences bet3een the t3o revie3ers1 a
thir! revie3er %SAS& ma!e the "inal !ecision as to 3hether the article shoul! be inclu!e!
or e@clu!e! "rom the sstematic revie3. SubseFuentl1 '2 stu!ies met the "inal inclusion
criteria "or this sstematic revie3.
Data &/traction
Stan!ar!iKe! !ata collection "orms 3ere use! to e@tract all !ata inclu!in6# stu! authors;
stu! site; ear an! !uration o" stu!; stu! !esi6n; population characteristics; sample
siKe; mental !isor!er stu!ie! an! the tool use! to screen an! !ia6nose the mental
!isor!er; !e"inition o" an! the tool use! to measure cA59 a!herence. In cases 3here no
stan!ar!iKe! tool 3as use! "or the mental !isor!er or cA59 a!herence1 the tools use! in
the stu!ies 3ere note! in the !ata collection "orm. 9he !ata collection "orm 3as similar to
9able 1 an! the !ata 3as e@tracte! at least t3ice "rom each article b one sin6le author
%AD&. 9he stu! characteristics in the tables 3ere evaluate! b one author %AD&. I"
inconsistencies in !e"initions o" a!herence or mental !isor!er 3ere i!enti"ie! then "urther
appraisal o" the particular issue 3oul! be carrie! out b t3o authors %AD an! MX& an!
note! in the tables. Jor e@ample1 i" it 3as i!enti"ie! that the stu! !i! not use a
stan!ar!iKe! tool to create a !e"inition o" !epression1 e.6. [!epression !e"ine! as ever
bein6 seen b a pschiatrist or ta4in6 AD9V1 then the problem 3ith the particular
!e"inition 3oul! be 3ritten in the e@traction table1 e.6. [!e"inition o" !epression 3as
mislea!in6 because it ma have inclu!e! persons 3ith a past me!ical histor o"
!epression 3ho are no lon6er !epresse! intro!ucin6 bias into resultsV.
Table 1
Impact o! depressive disorders on cA3T adherence" stud# characteristics
In or!er to clearl present the results1 the !ata 3ere separate! into "our cate6ories
accor!in6 to the mental !isor!er that 3as the main "ocus o" the stu!ies. 9able 1
summariKes stu!ies that evaluate! [the impact o" !epressive !isor!ers on cA59
a!herence an! persistenceV. 9hese constitute! the maAorit o" articles revie3e! %B2)'2;
-B C&. 9ables 21 3 an! , are presente! as an electronic appen!i@. 9able 2 summariKes
stu!ies that e@amine! the [impact o" speci"ic mental !isor!ers other than !epression on
cA59 a!herence an! persistenceV. 9able 3 presents stu!ies that evaluate! the [impact o"
mental !isor!ers not speci"ie! per DSM=I< !ia6nostic criteria on cA59 a!herence an!
persistenceV. Jinall1 9able , summariKes articles that evaluate! [the impact o"
pharmacolo6ic anti!epressant treatment %AD9& on cA59 a!herenceV amon6 P8?/A
3ith comorbi! !epressive !isor!ers. Due to the len6th an! scope o" the manuscript1
behavioral treatments o" !epressive !isor!ers 3ere not inclu!e! in this sstematic revie3.
In cases 3hen cA59 persistence 3as measure! instea! o" cA59 a!herence1 the term use!
b the authors 3as note! in the tables.
0o to"
"esults
9his sstematic revie3 e@amines '2 stu!ies evaluatin6 the impact o" mental !isor!ers
an! mental !isor!er smptoms %inclu!in6 moo!1 an@iet1 pschotic1 an! personalit
!isor!ers& on t3o primar outcomes# a!herence to1 an! persistence on cA59 %see
9ables 1 in the manuscript an! the 9ables 21 3 an! , 3ithin the electronic appen!i@&.
Antiretro-iral Adherence %easurements
A!herence to cA59 3as assesse! usin6 multiple metho!s %as hi6hli6hte! in the 9ables&.
Sevent=seven o" the articles use! onl one measurement o" a!herence1 "our stu!ies use!
t3o a!herence measurements an! one use! three !i""erent measures o" cA59 a!herence.
9hese inclu!e!# sel"=reports %participants recall& %* D B+&1 electronic !ru6 monitors
%IDMs& %* D *&1 pharmac re"ill recor! revie3 %* D B&1 hospital or clinic recor! revie3
%* D 2&1 unannounce! pill counts %* D +&1 an! !irectl observe! therap %D$9& %* D 1&1
an! some o" the stu!ies use! a combination o" the a"orementione! measures o" a!herence
to cA59 %* D +&.
9he time perio! over 3hich a!herence 3as assesse! ran6e! "rom 1 !a to 1 ear prior to
the intervie3. Amon6 the sel"=report instruments1 a!herence recall perio!s ran6e! "rom#
1 !a to , 3ee4s; - !as %the most commonl use! recall perio!& %* D 22 stu!ies&;
, 3ee4s %* D 12 stu!ies&; , !as %* D 12 stu!ies&; 3 !as %* D 10 stu!ies&; 2 !as %* D B
stu!ies&; 3 months %* D , stu!ies&; 1 !a %* D , stu!ies&; 2 3ee4s %* D 3 stu!ies&1 an!
+ !as %* D 1 stu!&. A!herence 3as reporte! either as a continuous or binar
%!ichotomous& measure1 either in association 3ith mental !isor!ers or as the proportion
o" the sample meetin6 a speci"ie! level o" a!herence. 9here 3as consi!erable variation
"or binar %!ichotomous& a!herence measure an! its cut=o""1 !i""erentiall !e"ine! b
stu!ies as N-+ C a!herence1 N'0 C a!herence1 N*0 C a!herence1 N*+ C a!herence1
100 C a!herence1 no misse! !oses1 or a speci"ic number o" misse! !oses "or a 6iven
perio! o" time.
Antiretro-iral Persistence %easurements
Amon6 "ive stu!ies that measure! cA59 re6imen persistence1 "our use! sel"=report
measures an! one use! IDMs1 sel"=report1 an! D$9 combine!. 9he time perio! over
3hich persistence 3as assesse! ran6e! "rom B months to 3 ears.
%easures of %ental Disorders
In a!!ition to ICD=*1 ICD=10 an! DSM=I< !ia6nostic criteria1 other vali!ate! an! non=
vali!ate! screenin6 tools %see 9able 1 in the manuscript an! 9ables 2 an! 3 in the
electronic appen!i@& 3ere use! to screen "or an! !ia6nose speci"ic mental !isor!ers an!
evaluate mental !isor!er smptoms. 9he most commonl evaluate! mental !isor!er 3as
!epressive !isor!er %* D B2&1 "ollo3e! b an@iet !isor!ers %* D 1-&1 bipolar !isor!er
%* D +&1 pschotic !isor!ers %* D 3&1 personalit !isor!ers %* D 2&1 an! a!Austment
!isor!er %* D 2&. Some stu!ies evaluate! more than one mental !isor!er an! use! more
than one instrument to evaluate the presence o" one or more mental !isor!ers. Depressive
!isor!er an! !epressive smptoms 3ere measure! b usin6 one or t3o sel"=report scales
in B0 stu!ies 3hereas t3o stu!ies use! a !ia6nosis o" !epression %ICD=* co!e& on
participantsV me!ical charts. 9he most common instrument emploe! to assess !epression
an! !epressive smptoms 3as the Center "or Ipi!emiolo6ical Stu!ies Depression Scale
%CIS=D& L,+1 ,BM1 %* D 23; 3- C& "ollo3e! b the Gec4 Depression Inventor %GDI an!
GDI=II& L,-(+0M %* D 1'; 2* C& an! the Structure! Clinical Intervie3 "or DSM=I<
%SCID& L+1M %"our stu!ies; B C&1 3ith the remainin6 stu!ies usin6 seventeen other scales#
Mont6omer(Asber6 Depression 5atin6 Scale %* D 3& L+2M1 Grie" Smptom Inventor
%GSI& %* D 3& L+3M1 /ospital An@iet an! Depression Scale %/ADS& %* D 2&1 Composite
International Dia6nostic Intervie3=Short Jorm %CIDI=SJ&1 Mini International
.europschiatric Intervie3 %MI.I& %* D 2&1 ICD=* %* D 2&1 /op4ins Smptom Chec4list=
1+1 GurnamVs intervie3er a!ministere! '=item screenin6 tool1 Sche!ule "or Clinical
Assessment in .europschiatr %SCA.&1 Pro"ile o" Moo! States %P$MS& !epression
"actor scale1 Grie" %sel"=report& screenin6 measures o" !epression %PC=SAD& L+,M1
;eriatric Depression Scale %;DS& L++M1 Patient /ealth Euestionnaire %P/E=*& %* D 2&
L+BM1 the '=item !epression scale "rom the Me!ical $utcomes Stu!1 the 1+=item
screenin6 test !evelope! an! use! previousl in 9hailan! %9hai Department o" Mental
/ealth1 200B&1 an! unspeci"ie! instruments constructe! "rom 3 to , Fuestions %* D 2
stu!ies& L+-1 +'M.
Primary #utcomes Analysis
93o outcomes 3ere evaluate! in this sstematic revie3# %a& cA59 a!herence an! %b&
cA59 persistence. A!herence an! persistence !ata "or each article 3ere e@tracte! an! are
presente! in 9ables 1 in the manuscript; an! 9ables 21 31 an! , in the electronic appen!i@.
9he "ollo3in6 sections are 6roupe! base! on each mental !isor!er an! the e""ect on these
t3o outcomes.
Adherence to cA"!
Impact of Depressive Disorders on cART Adherence
Ji"t=ei6ht stu!ies evaluate! the impact o" !epressive !isor!er %as either the !epen!ent or
in!epen!ent variable& on cA59 a!herence. 9hese !ata are presente! in 9able 1.
Depressie Disorders (ssociated /ith Decreased (dherence to c(+#. Depressive
!isor!ers 3ere si6ni"icantl associate! 3ith !ecrease! cA59 a!herence in thirt out o" +2
stu!ies %+- C&. Amon6 these thirt stu!ies1 thirteen 3ere cohort L+*(-1M1 one 3as a
ran!omiKe! control trial %5C9& L-2M1 an! 1B 3ere cross=sectional stu!ies L2*1 +-1 -3('BM.
9he maAorit o" these stu!ies use! sel"=report measures "or assessin6 the cA59 a!herence
variable %* D 2+)301 '3 C&1 3hile the other "ive stu!ies use! IDMS1 pharmac re"ill !ata
an! unannounce! pill counts to assess a!herence. Depression smptom measures 3ere
use! in the maAorit o" these stu!ies to assess the variable [!epressionV1 3ith the CIS=D
%* D 13& an! the GDI %* D -& as the most common measures. 93ent=seven o" the thirt
stu!ies %*0 C& use! multivariate analsis to evaluate the association 3ith !epressive
smptoms)!ia6nosis an! poor cA59 a!herence.
Depressie Disorders not Significantly (ssociated /ith (dherence to c(+#. 93ent=t3o
stu!ies !i! not "in! a statisticall si6ni"icant association bet3een !epression an!
!ecrease! cA59 a!herence. Si@teen 3ere cross=sectional L3,(3B1 +'1 '-(*'M1 3hereas si@
3ere cohort stu!ies L3'1 **(103M. 9he maAorit o" these stu!ies utiliKe! a !ia6nosis o"
!epressive !isor!er at baseline %either via the SCID1 MI.I1 CIDI1 /ADS1 or ICD=* co!e&
as the !epression variable %* D 10&1 3hile seven stu!ies use! a !epressive smptom scale1
an! the remain!er o" the stu!ies utiliKe! other non=stan!ar!iKe! measures to !etermine
!epressive smptoms)!isor!er1 such as the /SC8 an! a non=speci"ie! scale. Multivariate
analses 3ere reporte! "or "in!in6 an association 3ith !epressive !isor!er or !epressive
smptoms an! cA59 a!herence in the maAorit o" these stu!ies. 9he maAorit o" stu!ies
utiliKe! sel"=report measures "or the a!herence variable.
(dherence 0ariable Predicts Depressie Symptoms. In si@ stu!ies1 !epression 3as the
!epen!ent variable 3hile a!herence to cA59 3as the in!epen!ent variable L10,(10*M.
Jive o" these stu!ies reporte! an association 3ith non=a!herence to cA59 an! hi6her
!epressive smptoms L10,(10'M. 9he one stu! that !i! not "in! a statisticall si6ni"icant
association bet3een cA59 a!herence an! !epression ha! a relativel smaller sample siKe
%* D ',& as compare! to the stu!ies that !i! "in! an association1 3as complete! earlier
than the other stu!ies %ear 1**-&1 an! onl use! a si@=point li4ert scale to measure
a!herence L10*M.
Impact of Anxiety Disorders on cART Adherence
9able 2 lists seventeen articles that evaluate! the impact o" one or more an@iet !isor!ers
on cA59 a!herence. An@iet !isor!ers inclu!e!# %i& unspeci"ie! an@iet !isor!er %* D '&1
%ii& 6eneraliKe! an@iet !isor!er %;AD1 * D 3&1 %iii& posttraumatic stress !isor!er %P9SD1
* D *&1 %iv& panic !isor!er %* D 3&1 %v& a6oraphobia %* D 1&1 or a combination o" the
above %see 9able 2 in the electronic appen!i@&.
)mpact of P#SD on c(+# (dherence. 9he relationship bet3een P9SD an! cA59
a!herence 3as e@amine! b nine stu!ies %"our cohort1 an! "ive cross=sectional stu!ies&.
93o stu!ies %one prospective cohort an! one cross=sectional& "oun! that P9SD 3as
si6ni"icantl associate! 3ith !ecrease! cA59 a!herence L331 3,M. Goth o" these stu!ies
utiliKe! sel"=report a!herence measures an! e@amine! results 3ith multivariate analses.
$ne o" these stu!ies use! the Post=9raumatic Dia6nostic Scale %PDS& an! the Impact o"
Ivent Scale %IIS& 3hile the other stu! use! the IIS onl.
In one stu!1 P9SD participants 3ere si6ni"icantl more li4el to a!here to cA59 than
!epresse! participants. In this stu!1 B* participants !ia6nose! 3ith P9SD or !epression
3ere classi"ie! into "our 6roups accor!in6 to the severit o" smptoms# %i& control %lo3
P9SD)lo3 !epression&; * D 22; %ii& P9SD %hi6h P9SD)lo3 !epression&1 * D 11; %iii&
!epresse! %lo3 P9SD)hi6h !epression&1 * D 12&; an! %iv& mi@e! %hi6h P9SD)hi6h
!epression&1 * D 2,&. 9he P9SD 6roup 3as si6ni"icantl more li4el to a!here to cA59
re6imens compare! to the !epresse! 6roup !urin6 the previous 3ee4 %$5 D 23.*1 *+ C
CI D 1.B0-(3+B.0-+& an! !urin6 the previous 2 3ee4s o" the stu! %$5 D 2-.++; *+ C
CI D 1.**(3'1.'2& L110M.
Si@ stu!ies %three cross=sectional1 t3o cohort an! one 5C9& "oun! no si6ni"icant
association bet3een P9SD an! cA59 a!herence L3B1 +*1 -21 *,1 1031 111M. A!herence
3as measure! usin6 sel"=report instruments in "ive stu!ies an! IDM in one stu!. P9SD
3as measure! usin6 the SCID %* D 2&1 PDS %* D 2&1 IIS %* D 1& an! a short "orm o" the
3i!el use! Davi!son 9rauma Scale %SPA.1 * D 1&.
)mpact of Panic Disorder on c(+# (dherence. 9hree stu!ies e@amine! the e""ect o" panic
!isor!er on cA59 a!herence. A stu! o" 11*10 participants "oun! that participants 3ith
panic !isor!er 3ere more li4el to be non=a!herent to cA59 than those 3ho 3ere not
!ia6nose! 3ith a mental !isor!er a"ter bein6 screene! 3ith the "ull CIDI LB'M. In the
remainin6 t3o cross=sectional stu!ies1 panic !isor!er !ia6nose! usin6 the SCID=I 3as not
si6ni"icantl associate! 3ith cA59 a!herence L3B1 *,M. 9hese t3o stu!ies use! sel"=report
instruments to measure a!herence to cA59.
)mpact of Generali1ed (n2iety Disorder 3G(D4 on c(+# (dherence. 9he impact o" ;AD
on cA59 a!herence 3as assesse! in three revie3e! articles.
$ne stu! reporte! that participants 3ith ;AD 3ere more li4el to be non=a!herent than
those 3ithout a mental !isor!er LB'M. 9his cohort stu! o" persons 3ith a !ia6nosis o"
;AD measure! a!herence b the AC9; -=!a recall metho!1 3hile the other t3o articles
that "oun! no si6ni"icant association bet3een ;AD an! cA59 a!herence 3ere cross=
sectional evaluations an! use! the AC9; 3=!a recall metho! L3B1 *,M. In one o" these
stu!ies the participants ha! to have associate! panic !isor!er in a!!ition to the ;AD1
there"ore ma4in6 the speci"ic association 3ith ;AD !i""icult to assess.
)mpact of "ther (n2iety Disorders 3(goraphobia, 5nspecified (n2iety Disorder4 on
c(+# (dherence. A6oraphobia 3as evaluate! as a separate !isor!er in one cross=sectional
stu! o" +,2 participants1 an! 3as not "oun! to be si6ni"icantl associate! 3ith cA59
a!herence L3BM. 9his stu! use! a sel"=report instrument to measure a!herence to cA59
an! a6oraphobia 3as !ia6nose! usin6 the SCID.
Ii6ht stu!ies e@amine! the association bet3een an unspeci"ie! an@iet !isor!er %!e"ine!
as either an@iet smptoms or an@iet !isor!ers in 6eneral& an! cA59 a!herence. In three
articles1 an@iet smptoms 3ere si6ni"icantl associate! 3ith !ecrease! cA59 a!herence
L101 3'1 111M. In these three stu!ies1 a!herence 3as measure! usin6 sel"=report
instruments %* D 2& an! pharmac re"ill %* D 1&. An@iet smptoms 3ere measure! usin6
the /ospital An@iet an! Depression Scale %/ADS1 * D 1&1 State=9rait An@iet Inventor
%S9AI1 * D 1&1 an! GSI %* D 1&. $ne o" these stu!ies reporte! the result base! on
multivariate analsis an! t3o o" them reporte! the results base! on bivariate analsis.
Jour stu!ies "oun! no statisticall si6ni"icant association bet3een an@iet an! non=
a!herence LB01 '31 *B1 10*M. In these "our stu!ies1 a!herence 3as measure! usin6 sel"=
report instruments. An@iet smptoms 3ere measure! usin6 /ospital An@iet an!
Depression Scale %/ADS1 * D 1&1 State=9rait An@iet Inventor %S9AI1 * D 1&1 Smptom
Chec4 8ist=*0=5evise! %* D 1&1 an! a sel"=a!ministere! Fuestionnaire)"ace=to="ace
intervie3 o" somatic smptoms o" an@iet %* D 1&. 9hree o" these stu!ies reporte! the
result base! on multivariate analsis 3hereas onl one o" them reporte! the results base!
on bivariate analsis. In another stu! o" unspeci"ie! an@iet !isor!er1 an@iet smptoms
si6ni"icantl pre!icte! that participants a!here! to cA59 L*1M. In this cross=sectional
stu! o" 120 participants 3ith non=speci"ic an@iet smptoms measure! 3ith the CIDI=
SJ scale1 cA59 a!herence 3as measure! usin6 "our !ichotomous non=a!herent Fuestions
base! on electronic me!ical recor!s.
Impact of Psychotic Disorder (Schizophrenia) on cART
Adherence
93o cross=sectional stu!ies !i! not "in! a statisticall si6ni"icant association bet3een
schiKophrenia)pschotic !isor!er an! cA59 a!herence L*,1 112M. In one o" these stu!ies
the presence o" a pschotic !isor!er amon6 mentall ill participants 3as con"irme! b a
re"errin6 mental health pro"essional1 3hile in the other stu! the presence o" pschotic
!isor!er amon6 tripl !ia6nose! participants 3ith /I<1 substance abuse an! mental
!isor!ers 3as con"irme! usin6 the SCID. Goth stu!ies use! sel"=report measures to
evaluate a!herence to cA591 ho3ever one stu! assesse! this 3ith the AC9; 3=Da
recall an! the other use! sel" report an! IDMs.
Impact of Personaity Disorders on cART Adherence
93o cross=sectional stu!ies e@amine! the association bet3een personalit !isor!ers
%bor!erline an! antisocial& an! cA59 a!herence. Goth o" these stu!ies utiliKe! the sel"=
report AC9; 3=!a recall a!herence measure1 but the !i""ere! in the subAect
populations. $ne stu! o" /I<S persons enrolle! in multi=site cohort stu! "oun! no
statisticall si6ni"icant association bet3een bor!erline or antisocial personalit !isor!ers
an! a!herence L3BM. 9he other stu! o" 10- /I<S participants 3ith co=occurrin6
substance use !isor!ers enrolle! in a metha!one pro6ram "oun! that bor!erline
personalit !isor!er 3as associate! 3ith non=a!herence to cA591 3hile antisocial
personalit !isor!er 3as not L*,M.
Impact of !ipoar Disorder on cART Adherence
9he e""ect o" havin6 bipolar !isor!er on cA59 a!herence 3as e@amine! in "our cross=
sectional stu!ies. $ne stu! reporte! that bipolar !isor!er 3as si6ni"icantl associate!
3ith !ecrease! a!herence to cA59 L3+M an! utiliKe! IDMs as the a!herence tool. In three
stu!ies1 bipolar !isor!er 3as not si6ni"icantl associate! 3ith !ecrease! a!herence to
cA59 L3B1 *,1 112M. A!herence tools an! subAect populations !i""ere! bet3een these three
stu!ies.
Impact of Somatization" Dissociation" Ad#$stment
Disorder and %nspeci&ed 'enta Disorders on cART
Adherence
$ne stu! "oun! that levels o" somatiKation uniFuel pre!icte! a!herence problems in a
multivariate mo!el L10*M. Another stu! "oun! that !issociation mo!erate! the e""ect o"
P9SD on a!herence resultin6 in lo3er o!!s o" cA59 a!herence %$5 D 0 0.*+1 p R 0.0+&.
P9SD smptoms 3ere si6ni"icantl associate! 3ith lo3er o!!s o" a!herence in
in!ivi!uals reportin6 hi6h levels o" !issociation %$5 D 0.'B1 p R 0.0+& but not in those
reportin6 lo3 levels o" !issociation %$5 D 1.021 p ] 0.0+& L3,M.
93o cross=sectional stu!ies "oun! no si6ni"icant association bet3een a!Austment !isor!er
an! cA59 a!herence L3B1 *,M. Goth o" these stu!ies utiliKe! the AC9; 3 =!a recall "or
cA59 a!herence assessment.
Si@ stu!ies inclu!e! in this sstematic revie3 assesse! the impact o" unspeci"ie! mental
!isor!ers on a!herence to cA59. In these papers1 mental !isor!er 3as either use! as a
6eneral term or combine! 3ith more than one mental !isor!er into one variable %see
9able 3 in the electronic appen!i@&. All si@ stu!ies %"our cross=sectional an! t3o cohort&
reporte! a si6ni"icant association bet3een the mental !isor!er an! !ecrease! a!herence to
cA59 LB1 113(11-M. A!herence 3as measure! usin6 sel"=report instruments in "ive stu!ies
an! IDMs in one stu!. Jive !i""erent instruments 3ere use! to measure the presence o"
a mental !isor!er %see 9able 3 in the electronic appen!i@&.
Persistence on cA"!
Impact of Depressive Disorder on cART Persistence
9hree stu!ies1 t3o lon6itu!inal cohort an! one 5C91 "oun! that !epression 3as
associate! 3ith !ecrease! cA59 persistence L311 11'1 11*M. Another stu! "oun! less
cA59 !iscontinuation in the "irst ear amon6 those 3ith !epressive !isor!er1 but there
3as no association 3ith cA59 persistence a"ter the "irst ear L120M.
Impact of !ipoar Disorder on cART Persistence
$ne cohort stu! conclu!e! that /I<S Me!icai! bene"iciaries 3ith severe a""ective
!isor!er %!e"ine! as havin6 bipolar !isor!er plus maAor !epressive !isor!er i!enti"ie! b
ICD=* co!es& 3ere si6ni"icantl less persistent in their use o" cA59 than those 3ithout
serious mental illness L121M.
Impact of Psychotic Disorder on cART Persistence
In one cohort stu!1 pschotic !isor!er %schiKophrenia& i!enti"ie! b ICD=* co!in6 3as
not si6ni"icantl associate! 3ith persistence on cA59 L121M.
Impact of %nspeci&ed 'enta Disorder on cART
Persistence
$ne cohort stu! o" ,1*'* P8?/A "oun! that compare! to participants 3ith no mental
!isor!ers1 the haKar! probabilit "or !iscontinuin6 cA59 3as si6ni"icantl lo3er in the
"irst an! secon! ears o" treatment amon6 those 3ith a severe mental !isor!er %!e"ine! as
ICD=* co!es "or schiKophrenia1 other pschoses an! bipolar !isor!er&. Amon6
participants 3ith mental !isor!ers1 those 3ith si@ or more mental health visits per ear
3ere si6ni"icantl less li4el to !iscontinue cA59 compare! 3ith participants 3ith no
mental health visits L120M.
Impact of Antidepressant !reatment on Adherence to cA"!
.ine stu!ies %seven cohort stu!ies1 one 5C91 an! one cross=sectional stu!& evaluate! the
impact o" pharmacolo6ic AD9 on a!herence to cA59 amon6 !epresse! P8?/A %see
9able , in the electronic appen!i@&. Seven stu!ies reporte! that pharmacolo6ic treatment
"or !epression 3as si6ni"icantl associate! 3ith increase! cA59 a!herence LB*1 122(
12-M1 3hile in one stu! AD9 o" !epression 3as associate! 3ith !ecrease! cA59
a!herence. In this stu!1 ho3ever1 pharmacotherap 3as .$9 speci"icall evaluate!. 9he
authors !e"ine! treatment o" !epression as# [seein6 a pschiatrist1 receivin6 a !ia6nosis o"
!epression1 or bein6 prescribe! AD9V L11M. 9here"ore1 the construct vali!it o" this stu!
is problematic since the emploe! !e"inition o" pschiatric treatment !i! not !istin6uish
the treatment o" !epression "rom a !ia6nosis o" !epression.
A 5C9 reporte! that participants receivin6 !irectl observe! "luo@etine "or the treatment
o" !epressive smptoms ha! similar cA59 a!herence compare! to participants in the
re"erral arm L12'M. 9his stu!1 ho3ever1 ha! hi6h !e6rees o" continuation o" cA59 at the
en! o" the stu! in both arms %-3 vs -+ C&1 su66estin6 an overall hi6h !e6ree o"
persistence on therap.
0o to"
Discussion
DSM=I< mental !isor!ers1 especiall !epressive !isor!ers1 are e@tremel common amon6
P8?/A an! have been associate! 3ith !ecrease! a!herence to cA59 an! increase!
mortalit L2*1 321 +-1 -3M. 9he literature concernin6 /I< an! mental !isor!ers is
sta66erin61 et the !ata has et to be ri6orousl appraise!. Althou6h a meta=analsis
stu!in6 the e""ect o" !epression on cA59 a!herence 3as recentl publishe! L3-M1 this is
to our 4no3le!6e the "irst sstematic revie3 to e@amine the impact o" all mental
!isor!ers1 3ith the e@ception o" substance use !isor!ers1 on cA59 a!herence an!
persistence amon6 P8?/A.
9he maAorit o" papers inclu!e! in this revie3 stu!ie! the impact o" !epression on cA59
a!herence an! persistence. 9hirt o" the +2 stu!ies %+- C& that stu!ie! a!herence as the
!epen!ent variable1 "ive out o" si@ stu!ies %'3 C& that stu!ie! a!herence as the
in!epen!ent variable1 an! three out o" the "our stu!ies %-+ C& that e@amine! persistence
reporte! that a !epressive !isor!er 3as associate! 3ith a !ecrease in cA59 a!herence an!
persistence. Amon6 these stu!ies1 *0 C base! their results on multivariate analsis
compare! to B0 C o" the stu!ies that !i! not "in! an association bet3een !epression an!
cA59 a!herence an! persistence. $ne stu! reporte! a !ecrease! probabilit o" cA59
!iscontinuation amon6 those 3ith !epressive !isor!ers in the "irst ear but not in
subseFuent ears L120M. 9his stu!1 ho3ever1 !i! not measure a!herence in itsel"1 but
rather cA59 !iscontinuation %cA59 persistence& an! !e"ine! it broa!l as ceasin6 cA59
or !roppin6 out o" active care. 9he 23 stu!ies that "oun! no si6ni"icant association
bet3een !epression an! a!herence an! persistence to cA59 also ten!e! to have a smaller
sample siKe %mean sample siKe D 1*+& as compare! to the 3+ stu!ies that "oun! positive
associations %mean sample siKe D ,--&.
Some o" the reasons "or 3h the stu!ies o" !epressive !isor!ers "oun! !i""erin6
associations 3ith a!herence to cA59 3ere li4el attribute! to the !i""erences in 3hether
the utiliKe! speci"ic !epression screenin6 measures)smptom ratin6 scales %CIS=D1 GSI1
P/E& or stan!ar! !ia6nostic tools o" !epressive !isor!er %SCID1 MI.I1 CIDI& to !e"ine
the variable o" [V!epressive !isor!erP. Most o" the stu!ies that !i! not report a si6ni"icant
association 3ith a!herence utiliKe! more stan!ar! !ia6nostic tools o" !epressive !isor!er
such as the SCID1 MI.I1 an! CIDI. It 3oul! be important "or "uture research evaluations
o" !epression in /I< a!herence research to improve !ata harmoniKation b utiliKin6 the
cate6oriKation o" !epression instruments that Simoni et al. L,2M !escribe! as "ollo3s# L1M
stan!ar!iKe! !ia6nostic intervie3s1 that are commonl use! to assess the cate6orical
!ia6nosis o" !epression base! on DSM or ICD criteria1 %inclu!in6 in this cate6or CIDI1
MI.I1 SCID1 /ADS1 GDI etc.& L2M !epression screenin6 instruments1 that provi!e
empiricall base! cut=o""s an! are use"ul as the basis "or re"errals to more comprehensive
evaluations or to estimate the prevalence o" possible !epression %inclu!in6 in this
cate6or CIS=D an! /SC8 etc.&1 an! L3M smptom=ratin6 scales1 that are use"ul "or
monitorin6 chan6e in !epression smptoms over time %inclu!in6 in this cate6or GDI1
CIS=D1 /SC81 MAD5S etc.& L,2M. Althou6h there is no 6ol!=stan!ar! "or evaluation o"
!epression1 it has been recommen!e! that researchers nee! to ma4e in"orme! choices
base! on the characteristics o" the stu! population an! the purpose o" the research L,2M.
It is clear "rom this revie3 that such ri6orous evaluation o" the stu! intentions nee!s to
be applie! in or!er to improve !ata harmoniKation e""orts in the "uture.
$ther causes o" !i""erences in results o" the !epression stu!ies 3ere li4el !ue to the
hetero6eneit o" the !ia6nostic an!)or screenin6 tools use! "or assessin6 !epression. Jor
instance the CIS=D1 i!enti"ie! as a stan!ar!iKe! tool to screen "or !epressive smptoms1
3as the most commonl use! instrument amon6 the papers inclu!e! in this revie3 an! it
has t3ent items1 but not all versions are DSM=I< compatible %i.e.1 earl versions !o not
inclu!e items that map !irectl onto DSM smptoms& L,2M. Perhaps some o" the
variabilit in stu!ies evaluatin6 the e""ect o" !epression on cA59 a!herence ma have
been associate! 3ith the !i""erent versions o" the CIS=D as 3ell as the !i""erent cut=o""s
use! to assess severit o" !epressive smptoms. >ni"orm assessment o" !epression is
essential in or!er to improve e""orts at !ata harmoniKation across stu!ies o" P8?/A.
/armoniKation o" !ata can increase the li4elihoo! o" "in!in6 an association 3ith a
common outcome variable such as !epression an! a!herence to cA59. Jurthermore1 i"
the 6oal o" the research stu! is to i!enti" in!ivi!uals 3ith a clinical !ia6nosis o" maAor
!epressive !isor!er1 investi6ators shoul! consi!er "ollo3in6 up in!ivi!uals 3ho screen
positive "or !epressive smptoms 3ith a "ull !ia6nostic intervie3 such as the SCID1
MI.I or CIDI1 all o" 3hich have been vali!ate! 3ith P8?/A in both !evelope! an!
!evelopin6 countries L,21 12*M. Investi6ators shoul! also be care"ul 3hen usin6 me!ical
recor!s %ICD=* or DSM=I< co!es& to i!enti" participants as havin6 a !ia6nosis o"
[!epressionV1 as 3as !one in a "e3 o" the evaluate! stu!ies. 9his particular metho! ma
misi!enti" a previous !ia6nosis o" !epression in a possibl success"ull treate!
participant thereb a""ectin6 the analsis o" the a!herence outcome variable.
9he maAorit o" the stu!ies %* D 1-)20 articles& evaluatin6 the impact o" [speci"ic mental
!isor!ers other than !epressionV on cA59 a!herence an! persistence %see 9able 2 in the
electronic appen!i@& assesse! an@iet !isor!ers. An@iet !isor!ers 3ere associate! 3ith
!ecrease! a!herence in seven o" the stu!ies Lunspeci"ie! an@iet !isor!er %* D 3&1 ;AD
%* D 1&1 P9SD %* D 2&1 panic !isor!er %* D 1&M; but no association 3as !etecte! in the
maAorit o" the stu!ies %* D 1+&& L>nspeci"ie! an@iet !isor!er %* D ,&1 ;AD %* D 2&1
P9SD %* D B&1 panic !isor!er %* D 2&1 an! a6oraphobia %* D 1&. Althou6h t3o stu!ies
Lunspeci"ie! an@iet !isor!er %* D 1&1 P9SD %* D 1&M reporte! !ata su66estin6 that
an@iet !isor!ers 3ere associate! 3ith increase! a!herence to cA591 one stu! 3as
con!ucte! 3ith a control 6roup o" participants 3ith hi6h levels o" !epression1 rather than
a tpical control 6roup 3ithout an mental !isor!er L110M; an! the secon! stu!1
conclu!e! that Oscreenin6 positive "or an an@iet !isor!er re!uce! the ris4 o" "ailin6 to
ta4e me!ications as !irecte!P L'*M. Althou6h the 6ross sample siKe o" these stu!ies seems
su""icient1 the number o" a""ecte! participants "or each speci"ic an@iet !isor!er ma in
e""ect not have been lar6e enou6h to reach statistical si6ni"icance. ;iven the hi6h li"etime
prevalence o" an@iet !isor!ers amon6 P8?/A %- C& L130M1 ho3ever1 stu!ies evaluatin6
in!ivi!ual an@iet !isor!ers are not su""icient in number. 9o obtain a better un!erstan!in6
o" the impact o" speci"ic mental !isor!ers on cA59 a!herence other than !epression1
"uture 3ell=!esi6ne! prospective cohort stu!ies an! 5C9s 3ith lar6er sample siKes "or
each speci"ic !isor!er shoul! be con!ucte! to assess "or causalit.
All o" the stu!ies assessin6 the impact o" [unspeci"ie! mental !isor!ersV on cA59
a!herence conclu!e! that mental !isor!ers are associate! 3ith !ecrease! a!herence to
cA59. Importantl thou6h1 all o" these stu!ies inclu!e! !epression)!epressive smptoms
as the mental !isor!er variable LB1 113(11-M. 9he result o" these stu!ies coul! there"ore
be attribute! to the !irect e""ect o" the !epressive !isor!er on a!herence to cA59. $nl
one stu!1 3hich assesse! cA59 persistence as the !epen!ent variable1 conclu!e! that a
severe mental !isor!er 3as si6ni"icantl associate! 3ith lo3er probabilit "or cA59
!iscontinuation in the "irst an! secon! ears %su66estin6 increase! cA59 persistence&1
compare! to participants 3ith no mental !isor!ers L120M. An a!!itional "in!in6 o" this
stu! 3as that persons 3ith a mental !isor!er an! 3ith si@ or more mental health visits
per ear 3ere si6ni"icantl less li4el to !iscontinue cA59 compare! to those 3ith no
mental health visits. It is there"ore plausible that increase! mental health visits in this
stu! contribute! to improve! cA59 persistence b enhancin6 lin4a6e to health care1
inclu!in6 /I<=associate! health=care L120M.
9he treatment o" !epression 3ith anti!epressants 3as "oun! to be associate! 3ith
improve! a!herence in seven o" the nine stu!ies %-' C& e@aminin6 this e""ect. $ne o"
these stu!ies ha! a ver small sample siKe o" onl nine participants on AD91 there"ore
ren!erin6 an conclusions Fuestionable L122M. 9hree o" the "our stu!ies that "oun!
improve! a!herence to cA59 amon6 participants a!herent to AD9 use! pharmac
recor!s to measure a!herence L1231 12+1 12-M. 9he use o" pharmac recor!s as the sole
in!icator o" a!herence coul! con"oun! the a!herence outcome as participants 3ho obtain
their anti!epressant me!ications !irectl "rom pharmacies are more li4el to pic4 up their
cA59 me!ications1 thus Ohi!in6P the !irect e""ect o" AD9 on cA59 a!herence %via the
improvement o" !epressive smptoms&. Jurthermore1 a!herence to one me!ication ma
in!icate a propensit to3ar!s a!herence in 6eneral. 9here"ore participants 3ho are
a!herent to AD9 ma be more li4el to a!here to cA59 simpl because the are more
a!herent as a rule1 an! not because o" improve! !epressive smptoms. In one stu! that
!i! not "in! an association bet3een AD9 an! cA59 a!herence1 startin6 pschiatric
treatment 3as broa!l !e"ine! as receivin6 a !ia6nosis o" !epression1 seein6 a
pschiatrist or ta4in6 AD91 there"ore ma4in6 the in!ivi!ual e""ects o" pharmacolo6ical1
an! non=pharmacolo6ical pschiatric treatment impossible to un"url L11M. A recent 5C9
o" 13- /I<S homeless an! mar6inall house! persons "oun! no si6ni"icant !i""erence in
cA59 a!herence amon6 those receivin6 !irectl observe! "luo@etine as compare! to the
those re"erre! to the communit "or pschiatric care L12'M. 9his stu! ho3ever ha! hi6h
levels o" persistence to cA59 at the en! o" stu! in both 6roups %-3 vs -+ C .S&1 as 3ell
as similar percenta6es o" viral suppression in both 6roups %speci"ic !ata not reporte!&.
9hese results su66est that perhaps persistence to cA59 ma be more si6ni"icant than
a!herence "or a !urable cA59 re6imen.
Issues re6ar!in6 !i""erences bet3een the stu!ies in speci"ic AD9s as 3ell as appropriate
in!ivi!ual !osin61 ho3ever1 ma4e interpretation o" the impact o" AD9 on cA59
a!herence "or !epression !i""icult. 8ittle evi!ence "rom ran!omiKe! controlle! clinical
trials is available to 6ui!e the pschiatric treatment o" P8?/A L131M. Some stu!ies1
ho3ever1 have sho3n that !epression can be e""ectivel treate! in P8?/A L132(13,M1
speci"icall usin6 selective serotonin reupta4e inhibitors %SS5Is& L13+1 13BM. Despite
some possible evi!ence base! "rom this revie3 that AD9 ma improve a!herence to
cA59 amon6 P8?/A 3ho have co=morbi! !epression1 it is still unclear at this time
3hether treatin6 !epressive !isor!ers 3ith AD9 improves a!herence to cA59. Althou6h
other AD9 besi!es SS5Is inclu!in6 citalopram L13-M an! tricclic anti!epressants L13B1
13'M1 have been sho3n to be e""ective in treatin6 !epression amon6 P8?/A1 SS5Is
L13B1 13*M are better tolerate! in P8?/A an! recommen!e! as "irst=line a6ents "or
!epression L1,0M. In !evisin6 research involvin6 anti!epressants "or P8?/A1 ho3ever1
clinicians shoul! control "or the sta6e o" /I< illness1 co=morbi! illnesses such as
hepatitis G an! C1 the potential "or !ru6 interactions 3ith cA591 tpe o" AD91 ma@imal
!osin6 an! participantsV pre"erences L1331 1,1(1,3M.
9his sstematic revie3 also i!enti"ie! a lar6e hetero6eneit o" measurements an!
!e"initions o" a!herence to cA59 in various stu!ies li4el contributin6 to the variation in
outcomes. $verall the maAorit o" stu!ies utiliKe! some "orm o" sel"=report1 3hile "e3er
utiliKe! IDMS1 pharmac re"ill revie3s1 an! unannounce! pill counts. 9here is no
universall accepte! [6ol!V stan!ar! "or the measurement o" cA59 a!herence L1,,M. Sel"=
report a!herence measures an! other in!irect measures such as IDMs an! pill counts
have been "oun! to !istin6uish bet3een clinicall meanin6"ul patterns o" me!ication=
ta4in6 behavior L1,+1 1,BM. Sel"=report1 ho3ever1 ten!s to overestimate a!herence b 10(
20 C as compare! to IDMs evaluations because sel"=report is susceptible to recall bias1
inaccurate memor an! potentiall to social !esirabilit bias L1,-(1,*M. Pharmac recor!
revie31 on the other han!1 has been sho3 to misclassi" participants as non=a!herent to
cA59 in up to ,3 C o" the time 3hen !isre6ar!in6 le"tover me!ication L1+0M. 9he
variations in measurements utiliKe! to evaluate a!herence to cA59 in the revie3e!
stu!ies1 as 3ell as the !e"inition o" recall perio!1 li4el contribute! to the 6reat variation
o" the primar outcome1 cA59 a!herence.
9here are some limitations to this revie3. Althou6h 3e 3ere ver ri6orous 3ith inclusion
criteria an! e@clusion criteria1 it is plausible that some relevant papers that shoul! have
been inclu!e! 3ere misse!. A!!itionall1 the e@clusion o" behavioral treatments "or
!epression an! other mental !isor!ers constitutes a limitation 3hen !iscussin6 the scope
o" mental !isor!er treatments. Gehavioral treatments have overall been "oun! to be
e""ective in the treatment o" mental !isor!ers1 but !ue to the len6th o" the paper an! the
lar6e Fuantit o" !ata to be processe! in the scope o" pharmacolo6ical treatment alone1 it
3as !eci!e! to not inclu!e stu!ies on behavioral treatments in this particular revie3. 9he
inclusion o" stu!ies "rom both !evelope! an! !evelopin6 countries also coul! have
intro!uce! bias into our "in!in6s since con"oun!in6 "actors such as barriers an!
"acilitators o" cA59 a!herence ma be speci"ic to !i""erent 6eo6raphic areas L1+1(1+3M.
In !evelopin6 countries1 "oo! insu""icienc L1+,(1+BM an! health sstem !e"iciencies
have been "oun! to un!ermine treatment continuit an! a!herence to cA59 L1+-M1
3hereas reli6iosit has been sho3n to be positivel correlate! 3ith cA59 a!herence
L1+'M. Conversel1 e@aminin6 !ata "rom !i""erent parts o" the 3orl! increases the
6eneraliKabilit o" our "in!in6s an! emphasiKes the 3i!esprea! nature o" both mental
!isor!ers an! /I<.
Despite the limitations o" the revie31 this is the "irst paper to e@haustivel revie3 stu!ies
evaluatin6 the association bet3een DSM=I< mental !isor!ers %e@clu!in6 substance use
!isor!ers& an! a!herence an! persistence to cA59 amon6 a!ult P8?/A. Most o" the
stu!ies inclu!e! in this revie3 stu!ie! the a!herence variable at a time perio! 3hen
cA59 3as more comple@1 reFuirin6 multi=!ose re6imens. Current pre"erre! once=!ail
!osin6 re6imens1 ho3ever1 have been recentl sho3n to improve a!herence L1+*(1B2M.
In a time 3hen cA59 comple@it has !ecrease! 3hile potenc o" re6imens has increase!1
persistence to cA59 ma be a superior in!icator o" /I< outcomes than cA59 a!herence
an! a better variable to evaluate L,1 1+*1 1B31 1B,M. 5ecent stu!ies have "oun! !ata
su66estin6 that a!eFuate cA59 a!herence ma not be the 4e "actor in viral suppression
L1B+M. Juture stu!ies shoul! evaluate the impact o" mental !isor!ers an! their treatment
on /I< outcomes other than a!herence such as ma@imal viral suppression %i.e. /I< <8
R,' copies)m8&1 neuroco6nitive !e"icits1 as 3ell as liver an! renal !s"unction.
0o to"
Conclusions
9he maAorit o" the stu!ies inclu!e! in this sstematic revie3 i!enti"ie! a si6ni"icant
association bet3een !epressive smptoms)!isor!er an! cA59 nona!herence an! non=
persistence. Data relate! to the impact o" speci"ic mental !isor!ers other than !epression
%an@iet !isor!ers1 bipolar !isor!er1 pschotic !isor!ers an! personalit !isor!ers& on
a!herence to cA59 are insu""icient an! inconsistent. Juture research shoul! "ocus
speci"icall on each o" these mental !isor!ers an! cA59 a!herence. A!!itionall1
common measures shoul! be use! to assess cA59 a!herence as 3ell as speci"ic mental
!isor!ers to improve !ata harmoniKation across stu!ies. Jurthermore1 the maAorit o"
e@istin6 !ata su66est that treatment o" !epression 3ith AD9 ma be associate! 3ith
improve! a!herence to cA59 amon6 P8?/A. Juture 5C9=!esi6ne! stu!ies 3ill nee! to
be con!ucte! to best !etermine the association bet3een improvement o" !epressive
smptomatolo6 an! cA59 a!herence. 8astl1 /I< outcomes other than a!herence to
cA591 such as ma@imal /I< viral loa! suppression an! neuroco6nitive !e"icits are
important to evaluate no3 that more potent combination antiretroviral re6imens are
available.
0o to"
&lectronic supplementary material
.upplementar# material 1 %,9C 11H 7b'
%11H>1 doc'
0o to"
Ac3nowled'ments
An6ela DiPaola "or her assistance in proo"rea!in6 this manuscript. Jun!in6 is provi!e!
b the .ational Institutes on Dru6 Abuse %202=DA032322& "or SAS
#pen Access
9his article is !istribute! un!er the terms o" the Creative Commons Attribution 8icense
3hich permits an use1 !istribution1 an! repro!uction in an me!ium1 provi!e! the
ori6inal author%s& an! the source are cre!ite!.
0o to"
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Jurnal +
P8oS $ne. 2012; -%+&# e3B30,.
Publishe! online 2012 Ma 1,. !oi# 10.13-1)Aournal.pone.003B30,
PMCID# PMC33+1,,1
Pre-alence of Psycholo'ical !rauma and
Association with Current Health and
,unctionin' in a Sample of HIV-infected
and HIV-uninfected !anFanian Adults
Grian ?. Pence1
11T
2risten Shire1
2
2athrn ?hetten1
1
Gernar! A6ala1
1
Da"rosa Itemba1
3

Julie A!ams1
2
5achel ?hetten1
1
Jia 0ao1
1
an! John Shao
3
8an!on Mer1 I!itor
Author in"ormation 7 Article notes 7 Copri6ht an! 8icense in"ormation 7
9his article has been cite! b other articles in PMC.
;o to#
Abstract
+ac3'round
In hi6h income nations1 traumatic li"e e@periences such as chil!hoo! se@ual abuse are
much more common in people livin6 3ith /I<)AIDS %P8?/A& than the 6eneral
population1 an! trauma is associate! 3ith 3orse current health an! "unctionin6. <irtuall
no !ata e@ist on the prevalence or conseFuences o" trauma "or P8?/A in lo3 income
nations.
%ethodolo'y1Principal ,indin's
?e recruite! "our cohorts o" 9anKanian patients in establishe! me!ical care "or /I<
in"ection %n D 22'&1 in!ivi!uals ne3l testin6 positive "or /I< %n D 2B-&1 in!ivi!uals
testin6 ne6ative "or /I< at the same sites %n D 1'2&1 an! a ran!om sample o" communit=
!3ellin6 a!ults %n D 2,*&. ?e assesse! li"etime prevalence o" traumatic e@periences1
recent stress"ul li"e events1 an! current mental health an! health=relate! phsical
"unctionin6. 9hose 3ith establishe! /I< in"ection reporte! a 6reater number o"
chil!hoo! an! li"etime traumatic e@periences %2.1 an! 3.0 respectivel& than the
communit cohort %1.' an! 2.3&. 9hose 3ith establishe! /I< in"ection reporte! 6reater
post=traumatic stress !isor!er %P9SD& smptomatolo6 an! 3orse current health=relate!
phsical "unctionin6. Iach a!!itional li"etime traumatic e@perience 3as associate! 3ith
increase! P9SD smptomatolo6 an! 3orse "unctionin6.
Conclusions1Si'nificance
9his stu! is the "irst to our 4no3le!6e in an /I< population "rom a lo3 income nation
to report the prevalence o" a ran6e o" potentiall traumatic li"e e@periences compare! to a
matche! communit sample an! to sho3 that trauma histor is associate! 3ith poorer
health=relate! phsical "unctionin6. $ur "in!in6s un!erscore the importance o"
consi!erin6 pschosocial characteristics 3hen plannin6 to meet the health nee!s o"
P8?/A in lo3 income countries.
;o to#
Introduction
In hi6h income nations1 stu!ies o" people livin6 3ith /I<)AIDS %P8?/A& have
consistentl !emonstrate! a hi6h li"etime prevalence o" traumatic li"e e@periences. L1M In
a lar6e >S cohort o" 3omen 3ith or at hi6h ris4 "or /I<1 BBC ha! e@perience! !omestic
violence an! 31C percent ha! e@perience! se@ual abuse !urin6 chil!hoo!.
2
9hese
numbers are substantiall hi6her than the 6eneral population li"etime prevalence o"
!omestic violence %2+C& an! chil!hoo! se@ual abuse %13C&. L2M1 L3M In a lar6e cohort o"
/I< patients "rom the >S Deep South1 30C o" participants reporte! se@ual abuse an!
20C reporte! phsical abuse !urin6 chil!hoo!; overall1 *1C o" respon!ents reporte! at
least one potentiall traumatic e@perience !urin6 their li"etimes. L,M1 L+M.
In recent ears1 increasin6 attention has turne! to the a!verse behavioral an! health
conseFuences o" trauma histories in P8?/A. LBM1 L-M A histor o" potentiall traumatic
li"e events has been associate! 3ith !evelopment o" post=traumatic stress !isor!er
%P9SD&1 L'M(L13M !epression1 L1,M(L1'M an! substance abuse1 L12M1 L1,M1 L1*M(L21M as 3ell
as increase! hi6h ris4 se@ual an! !ru6 use behaviors that increase the ris4 o" becomin6
in"ecte!1 an! transmittin6 in"ection to others. L1,M1 L22M(L2'M 9hou6h rates o" P9SD have
not been stu!ie! in lar6e cohorts1 e@istin6 !ata1 pre!ominatel "rom hi6h income
countries1 su66est that P9SD is hi6hl prevalent amon6 P8?/A. In a stu! o" 3+0
count=base! /I< primar care clinic patients1 3,C met screenin6 criteria "or P9SD.
L2*M A recent meta=analsis o" +1*30 /I< positive 3omen !emonstrate! rates o" probable
P9SD o" 30C1 3hich is "ive times hi6her than the rates o" P9SD amon6 3omen in the
6eneral >.S. population. L30M Moreover1 those 3ith a histor o" traumatic e@periences
have lo3er me!ication a!herence1 6reater emer6enc !epartment utiliKation1 "aster
pro6ression to AIDS1 an! hi6her mortalit rates. L31M(L3,M.
A histor o" traumatic e@periences also pre!icts poorer current health=relate! phsical
"unctionin6 in P8?/A. L31M Current phsical "unctionin6 is an important outcome to
consi!er in its o3n ri6ht !ue to the correlation o" lo3er phsical "unctionin6 3ith lo3er
CD, counts1 hi6her viral loa!s1 an! re!uce! survival rates. L3+M(L3'M ;iven the chronic
nature o" /I< in"ection1 phsical "unctionin6 ma have important implications "or pain1
abilit to 3or41 an! activities o" !ail livin6 over a perio! o" man ears.
.earl all research on the impact o" past trauma on current health an! "unctionin6 "or
P8?/A has ta4en place in hi6h income nations. In sub=Saharan A"rica1 home to t3o
thir!s o" the 3orl!Vs population o" P8?/A1 L3*M there is limite! !ata about e@posure to
potentiall traumatic events or their phsical an! mental health seFuelae. Amon6 a cohort
stu! o" ,, /I< positive patients in a 6enitourinar me!icine clinic in the ;ambia1
,3.2C en!orse! P9SD smptoms. L,0M A South A"rican stu! con!ucte! to vali!ate the
use o" the 1- item Posttraumatic stress Dia6nostic Scale %PDS& in a South A"rican patient
population survee! a convenience sample o" '+ recentl !ia6nose! /I< positive
patients. Amon6 this sample1 ,,C met !ia6nostic criteria "or current P9SD L,1Man! +,C
met criteria "or li"etime prevalence o" P9SD. L,2M $utsi!e o" this South A"rican stu!1
!ata are sparse re6ar!in6 not onl the prevalence o" traumatic e@posure in P8?/A1 but
also the relationship bet3een traumatic e@posure an! current mental health an! health=
relate! phsical "unctionin6.
?ith the rapi! e@pansion o" access to antiretroviral therap in lo3 income nations1 it is
criticall important to un!erstan! the prevalence o" trauma histor in P8?/A in the
re6ion as 3ell as its in"luence on mental health an! "unctionin6. Accor!in6l1 the purpose
o" the present paper is to !escribe the li"etime prevalence o" potentiall traumatic
e@periences in a sample o" /I<=positive an! /I<=ne6ative 9anKanian a!ults an! to
e@amine associations bet3een li"etime trauma histor1 current mental health1 an! health=
relate! phsical "unctionin6.
;o to#
%ethods
9he Copin6 3ith /I<)AIDS in 9anKania %C/A9& Stu! is an observational cohort stu!
!esi6ne! to e@plore the lon6itu!inal relationships bet3een pschosocial characteristics1
/I< me!ication a!herence1 an! health outcomes amon6 /I<=positive in!ivi!uals in
9anKania. 9his stu! an! all stu! activities 3ere speci"icall approve! b the
2ilimanAaro Christian Me!ical Center Institutional 5evie3 Goar! in 9anKania an! the
Du4e >niversit /ealth Sstem Institutional 5evie3 Goar! in the >nite! States1 an!
3ritten in"orme! consent 3as obtaine! "rom all participants.
Jrom .ovember 200' to $ctober 200*1 the C/A9 Stu! recruite! 111*- participants to
"orm "ive !istinct cohorts# patients 3ith establishe! /I< in"ection receivin6 care at the
re6ional tertiar re"erral hospital %2CMC1 clinic census 1,00; sample n D 22'&; patients
3ith establishe! /I< in"ection receivin6 care at the local public hospital %clinic census
2-00; sample n D 2-1&; in!ivi!uals ne3l !ia6nose! 3ith /I< at voluntar counselin6
an! testin6 %<C9& sites %n D 2B-&; in!ivi!uals testin6 /I<=ne6ative at <C9 sites %n D
1'2&; an! a ran!om sample o" a!ults "rom the surroun!in6 communit %n D 2,*&.
Speci"ic recruitment proce!ures 3ere as "ollo3s. Jor the t3o clinical cohorts1 an patient
a6e! 1'(B+ resi!in6 in Moshi >rban an! /ai !istricts o" the 2ilimanAaro re6ion 3ith
plans to sta in the re6ion "or the "oreseeable "uture 3as eli6ible to participate. Due to
sta""in6 an! intervie3 len6th1 a ma@imum o" 3 participants)clinic !a coul! be enrolle! at
each clinic. At both clinics1 it 3as estimate! that at least 30C o" patient visits 3ere
unsche!ule!1 an! there 3as a 3i!e variation in the number o" patients presentin6 on an
6iven clinic !a. 9here"ore1 patients 3ere selecte! b a ran!om time point sstem. In
or!er to construct the selection parameters "or the ran!om time selection1 clinic "lo3 3as
observe! over the perio! o" one 3ee4. Jrom that 3ee41 the earliest arrival time o" the
secon! patient o" the !a an! the latest arrival time o" the ne@t=to=last patient o" the !a
3ere !esi6nate! as the be6innin6 an! en!in6 times "or the time point samplin6. 9hree
minutes "rom the clinic !a 3ere ran!oml selecte!1 3ith probabilit o" selection
proportional to the e@pecte! number o" patients in a 6iven time interval. 9he selecte!
minutes "or each !a 3ere !istribute! to the clinic nurses an! pro6ramme! into alarms
place! at the nursin6 tria6e station. A"ter an alarm 3ent o""1 the ne@t patient in line "or
tria6e 3as screene! "or eli6ibilit an!1 i" eli6ible1 rea! a stan!ar!iKe! brie" !escription o"
the research. Patients 3ho 3ere intereste! an! !esire! "urther in"ormation un!er3ent the
"ull consent process 3ith a research sta"". I" the selecte! patient !ecline! or 3as
ineli6ible1 the ne@t patient 3as approache! as a replacement.
9he cohorts o" in!ivi!uals ne3l testin6 /I<=positive an! =ne6ative at <C9 sites 3ere
recruite! as "ollo3s. All people 1'(B+ ears ol! an! presentin6 "or testin6 at , <C9 sites
in Moshi >rban 3ere eli6ible "or enrollment. Iver eli6ible client receivin6 a positive
/I< test 3as invite! to participate1 an! a"ter ever other person testin6 positive1 the ne@t
client testin6 ne6ative 3as also invite!. I" a client re"use! to participate the ne@t client
3as as4e! to replace them. Clients 3ere invite! a"ter receivin6 the results o" their /I<
test. 9he either complete! the intervie3 imme!iatel %3'C o" those testin6 positive an!
+'C o" those testin6 ne6ative& or ma!e an appointment to return "or the intervie3 %3ithin
- !as# ,*C o" those testin6 positive an! 3BC o" those testin6 ne6ative; more than one
3ee4 later# 13C o" those testin6 positive an! BC o" those testin6 ne6ative&. Althou6h the
lar6e maAorit o" clients at these <C9 sites came on their o3n1 occasionall couples
presente! "or testin6 to6ether; o" ,,* total participants enrolle! "rom <C9 sites1 3
couples 3ere enrolle!.
9he communit sample 3as recruite! "rom househol!s in the three !istricts
correspon!in6 to the maAorit o" the catchment areas o" the , <C9 centers# Moshi >rban1
Moshi 5ural1 an! /ai !istricts. Jrom the list o" streets in each !istrict1 2+C o" the streets
3ere ran!oml selecte! %Moshi >rban (1+ out o" B0 streets1 Moshi 5ural (- out o" 30
streets an! /ai (3 out o" 10 streets&. Street 8ea!ers %each street has a !esi6nate! Street
8ea!er& 3ere approache! "or lists o" househol!s on that street an! the respective hea!s o"
those househol!s. 9en househol!s "rom each street 3ere then ran!oml selecte!. 9he
hea! o" each selecte! househol! 3as then as4e! i" the househol! 3oul! participate in the
stu!. I" the hea! o" the househol! a6ree!1 a census o" househol! members bet3een 1'
an! B+ ears 3as ta4en. All those liste! in the census re6ister 3ere as4e! i" the 3oul!
li4e to participate an! o" those 3ho a6ree!1 one 3as ran!oml selecte! throu6h a
ran!omiKation sche!ule. 5ecruitment "or the communit sample 3as per"orme! 3ithout
4no3le!6e o" /I< status.
Participants complete in=person intervie3s ever si@ months 3ith traine! local
intervie3ers not previousl 4no3n to the participants; these intervie3s last appro@imatel
one hour. /I<=in"ecte! participants 3ho have initiate! clinical care also complete clinical
e@ams an! provi!e bloo! "or CD, counts an! /I< 5.A viral loa!s on the same sche!ule.
All intervie3s are con!ucte! in S3ahili1 3ith instruments translate! "rom an! bac4=
translate! to In6lish to con"irm the vali!it o" the translation. 9he present manuscript
"ocuses on the baseline in=person intervie3 onl. 9he analses e@clu!e the cohort "rom
the local public hospital1 "or 3hom the Fuestions about trauma histor at baseline 3ere
a!ministere! inconsistentl.
%easures
Participants sel"=reporte! socio!emo6raphic in"ormation inclu!in6 a6e1 6en!er1 marital
status1 hi6hest level o" complete! e!ucation1 reli6ion1 househol! assets1 an! tribe. "erall
health6related physical functioning 3as assesse! 3ith the Short Jorm %SJ&='1 a vali!ate!
shortene! version o" the e@tensivel use! SJ=3B. L,3M1 L,,M 9he Phsical Composite
Score %PCS& 3as compute! accor!in6 to stan!ar! metho!olo6; this score is a 3ei6hte!
avera6e o" the SJ=' items 3ith heaviest 3ei6hts 6iven to Fuestions "ocusin6 on overall
perception o" phsical health1 health phsical "unctionin6 %e.6.1 !e6ree to 3hich health
inter"eres 3ith 3al4in6 an! li"tin6&1 "unctionin6 3ithout bo!il pain1 an! health role
"unctionin6 %e.6.1 e@tent to 3hich health limits 3or4 an! activities&. 9he score can ran6e
"rom 0(1001 3ith hi6her scores in!icatin6 better health=relate! phsical "unctionin6 an!
10 units representin6 one stan!ar! !eviation in the >S normative population. L,+M.
Depressive severit 3as assesse! 3ith the Patient /ealth Euestionnaire=* %P/E=*&1 a
3i!el use! !epression case i!enti"ication tool 3hich has been vali!ate! in A"rican
populationsL,BM1 L,-M an! has a possible ran6e o" 0(2- 3ith hi6her scores in!icatin6
6reater !epressive severit. L,'M1 L,*M Post6traumatic stress disorder 3P#SD4 symptom
seerity 3as assesse! 3ith the P9SD Smptoms Chec4list %PC8& base! on DSM=I<
criteria that inclu!e re=e@periencin6 a traumatic event1 numbin6)avoi!in61 an!
hperarousal smptoms. 9his scale has stron6 reporte! reliabilit1 an! correlates hi6hl
3ith a clinician=a!ministere! P9SD measure. L+0M1 L+1M.
Potentiall traumatic e@periences 3ere !e"ine!1 "or the purposes o" this stu!1 as events
that 3oul! satis" criterion A%1& o" the !e"inition o" P9SD in the Dia6nostic an!
Statistical Manual o" Mental Disor!ers %DSM=I< (95&. L+2M 9he number o" cate6ories o"
li"etime potentiall traumatic events 3as measure! 3ith a Fuestionnaire1 a!apte! "rom
prior research b 8eserman an! collea6ues1 3hich inclu!e! !etaile! Fuestions about
se@ual abuse an! severe phsical trauma %a6e1 number o" e@periences1 perpetrator1 etc.&1 a
stan!ar!iKe! assessment o" chil!hoo! phsical an! emotional ne6lect1 L+3M an! in!ivi!ual
Fuestions as4in6 about other potentiall traumatic e@periences. L31M1 L+3M(L+BM Se@ual
abuse 3as !e"ine! in the analsis to inclu!e se@ual e@periences %e.6.1 touchin61
intercourse& 3here "orce or threat o" "orce 3as use!; ho3ever1 in chil!ren %be"ore the a6e
o" pubert& the threat o" "orce or harm 3as implie! b a +=ear a6e !i""erential bet3een
the victim an! perpetrator. Phsical abuse 3as !e"ine! as inci!ents separate "rom se@ual
abuse that 3ere perceive! to be li"e threatenin6 %bein6 phsicall attac4e! 3ith the intent
to 4ill or seriousl inAure&1 an! other phsical abuse %bein6 beaten1 hit1 4ic4e!1 bit1 or
burne!&. Chil!hoo! phsical an! emotional ne6lect 3as measure! 3ith the Chil!hoo!
9rauma Euestionnaire an! score! usin6 the cuto""s su66este! b Gernstein an! Jin4 "or
mo!erate phsical ne6lect %N*& an! mo!erate emotional ne6lect %N12&. L+3M $ther
potential traumas be"ore a6e 1' 3ere parental alcohol)!ru6 abuse1 !epression1 suici!e or
attempte! suici!e; imprisonment o" a parent; !omestic violence in the home; bein6 place!
in re"orm school1 prison or Aail1 or "oster or a!optive care; !eath o" an imme!iate "amil
member; an! havin6 a li"e=threatenin6 illness or inAur not relate! to /I<. 8i"etime
potential traumas inclu!e! mur!er or !eath b trauma o" a close "amil member1 !eath o"
a chil!1 an! !eath o" a spouse)partner. Participants 3ere assi6ne! a score "rom 0 to 1+
re"lectin6 the number o" tpes o" potentiall traumatic events e@perience! in their
li"etime. 9his speci"ication o" the number o" tpes o" potentiall traumatic events
e@perience! has been use! 3i!el an! has been associate! 3ith multiple ne6ative health
outcomes. L31M1 L3,M1 L+-M(L+*M.
5ecent stress"ul li"e events 3ere measure! 3ith a mo!i"ie! version o" the 8i"e Ivents
Surve %8IS&LB0M1 LB1M to measure the occurrence o" stress"ul events in the B months
prece!in6 the baseline intervie3. $nl those events consi!ere! to be mo!eratel to
severel stress"ul base! on previous stu!ies 3ith intervie3er=base! obAectivel rate!
stresses 3ere inclu!e!. L31M1 LB2M Mo!erate stressors inclu!e! e@periences such as
relationship !i""iculties; !eath or serious illness o" a close "rien! or e@ten!e! "amil
member; emploment !i""iculties %e.6. loss o" Aob&; an! non=/I<=relate! serious illnesses1
inAuries1 an! acci!ents. Severe stressors inclu!e! !ivorce)separation1 !eath or illness o" an
imme!iate "amil member1 maAor "inancial problems %e.6.1 loss o" home&1 more than a
3ee4 in prison1 an! se@ual an! phsical assault.
Statistical Analyses
$r!inar least sFuares re6ression 3as use! to assess the association o" measures o"
potentiall traumatic an! stress"ul li"e e@periences 3ith three measures o" mental health
an! health=relate! phsical "unctionin6 at the time o" the baseline visit# P9SD smptom
severit1 !epressive smptom severit1 an! SJ=' health=relate! phsical "unctionin6
composite score. ?e inclu!e! "i@e! e""ects "or the "our cohorts in each mo!el. ?e
e@amine! 3hether the associations o" li"e events 3ith outcomes varie! across the "our
cohorts b Aointl testin6 a set o" interaction terms bet3een the site "i@e! e""ects an! the
li"e events measure in each mo!el. ?e assesse! the appropriateness o" a linear
speci"ication o" each continuous li"e events measure b testin6 the si6ni"icance o" a!!in6
a Fua!ratic term.
?e hpothesiKe! that li"etime potentiall traumatic events mi6ht in"luence current P9SD
smptomatolo6 throu6h recent stress"ul li"e events an! !epressive smptoms1 an! that
li"etime potentiall traumatic events mi6ht in"luence current health=relate! phsical
"unctionin6 throu6h recent stress"ul li"e events !epressive smptoms1 an! P9SD
smptoms. 9o e@plore these hpotheses "or the outcome o" P9SD smptomatolo61 3e
"irst built a mo!el that inclu!e! the continuous measure o" li"etime potentiall traumatic
events as 3ell as site "i@e! e""ects an! socio!emo6raphic variables as covariates %Mo!el
1&. Mo!el 2 inclu!e! all Mo!el 1 variables as 3ell as the measure o" recent stress"ul li"e
events1 an! Mo!el 3 inclu!e! all Mo!el 2 variables as 3ell as !epressive smptoms. Jor
the outcome o" health=relate! phsical "unctionin61 Mo!els 1(3 3ere speci"ie! similarl1
an! 3e a!!e! a Mo!el , 3hich inclu!e! all Mo!el 3 variables as 3ell as P9SD
smptomatolo6. ?e assesse! 3hether these variables me!iate! the association o"
li"etime potentiall traumatic events 3ith current P9SD smptoms or health=relate!
phsical "unctionin6 b e@aminin6 shi"ts in the ma6nitu!e o" the coe""icient "or li"etime
potentiall traumatic events as the hpothesiKe! me!iators 3ere pro6ressivel a!!e! to
the mo!el.
;o to#
"esults
Sample Description
9he "our cohorts inclu!e! *2B participants %2,* communit members1 1'2 ne3l teste!
/I<=ne6ative1 2B- ne3l teste! /I<=positive1 an! 22' 3ith establishe! /I< in"ection&
%9able 1&. 5esponse rates %the proportion o" all those eli6ible an! approache! 3ho
provi!e! in"orme! consent& 3ere *'C %communit&1 ''C %ne3l teste! /I<=ne6ative&1
*BC %ne3l teste! /I<=positive&1 an! 100C %establishe! /I< in"ection&. 9hose ne3l
testin6 /I<=ne6ative an! /I<=positive 3ere oun6er on avera6e %mean 32.2 ears an!
3-.+ ears1 respectivel& than the communit sample %mean 3*.B ears&1 3hile those 3ith
establishe! /I< in"ection 3ere ol!er %mean ,2.B ears&. 9hose ne3l testin6 /I<=
ne6ative 3ere evenl !ivi!e! bet3een males an! "emales1 3hereas about t3o=thir!s o"
those ne3l testin6 /I<=positive an! those 3ith establishe! /I< in"ection 3ere "emale.
9he ne3l teste! /I<=ne6ative in!ivi!uals 3ere comparable in phsical an! mental
health scores to the communit sample 3ith the e@ception o" elevate! P9SD smptom
severit. 9hose ne3l testin6 /I<=positive an! those 3ith establishe! /I< in"ection ha!
3orse overall phsical an! mental health scores an! 6reater P9SD smptom severit
compare! to the communit cohort1 an! those ne3l testin6 /I<=positive also ha!
elevate! !epressive smptoms compare! to the other cohorts.
9able 1
Characteristics of Sample8
!raumatic and Stressful &-ents
9hose 3ith establishe! /I< in"ection ha! the hi6hest e@posure to chil!hoo! %mean# 2.1
tpes o" trauma& an! li"etime %mean# 3.0& potentiall traumatic e@periences %9able 1&. 9he
e@posure o" those ne3l testin6 /I<=positive %chil!hoo!# 1.-; li"etime# 2.2& 3as
comparable to the communit cohort %chil!hoo!# 1.'; li"etime# 2.3&1 3hereas those ne3l
testin6 /I<=ne6ative ha! lo3er e@posure than the communit cohort %chil!hoo!# 1.+;
li"etime# 1.*&. 5ecent stress"ul li"e events 3ere comparable bet3een the communit
cohort %mean# ,.2 events in past B months& an! those 3ith establishe! /I< in"ection %,.1
events&1 3hile those ne3l testin6 /I<=ne6ative %3.2 events& an! /I<=positive %2.*
events& ha! "e3er recent stress"ul li"e events.
9he most common tpe o" potentiall traumatic e@perience in all cohorts 3as chil!hoo!
phsical ne6lect1 reporte! b over hal" o" the communit cohort an! those 3ith
establishe! /I< in"ection an! b one=thir! o" those ne3l testin6 /I<=ne6ative an! /I<=
positive %9able 2&. $ther common potentiall traumatic e@periences "rom chil!hoo!
inclu!e! parental use o" alcohol or !ru6s in the home1 reporte! b one=Fuarter to one=hal"
o" all cohorts1 an! !eath o" a close relative1 reporte! b one=Fuarter to one=thir! o" all
cohorts. Parental mental illness1 suici!e attempt1 or success"ul suici!e 3as reporte! b ,(
-C o" respon!ents1 !epen!in6 on the cohort.
9able 2
Pre-alence of lifetime potentially traumatic e/periences8
In a!ulthoo!1 2+C o" those 3ith establishe! /I< in"ection an! 1,(1+C o" those in the
other cohorts ha! lost a chil!. In a!!ition1 32C o" those 3ith establishe! /I< in"ection
an! 1'C o" those ne3l testin6 /I<=positive ha! lost a spouse or partner1 compare! to B(
*C o" those in the communit cohort or ne3l testin6 /I<=ne6ative.
Se@ual abuse be"ore pubert 3as reporte! b B(11C o" respon!ents1 !epen!in6 on the
cohort1 an! se@ual abuse a"ter pubert 3as reporte! b 3('C o" respon!ents. About one=
thir! o" those reportin6 se@ual abuse be"ore pubert also su""ere! se@ual abuse a"ter
pubert. Severe phsical abuse be"ore pubert 3as reporte! b 2(+C o" respon!ents1
3hile phsical abuse or assault a"ter pubert 3as reporte! b B(10C o" respon!ents.
!rauma History and Current Health
;reater e@posure to potentiall traumatic e@periences 3as associate! 3ith 3orse sel"=
reporte! mental health an! health=relate! phsical "unctionin6 measures %9able 3&.
Controllin6 "or cohort "i@e! e""ects1 in bivariate analses each a!!itional li"etime
potentiall traumatic e@perience 3as associate! 3ith an increase o" 0.B %*+C CI# 0.21 0.*&
units on the P9SD smptomatolo6 scale1 an increase o" 0.+ %0.21 0.-& units on the P/E=
* !epressive smptoms scale1 an! a !ecreases o" ^0.- %^1.11 ^0.2& units on the SJ='
health=relate! phsical "unctionin6 composite score. ?hen attention 3as restricte! to
chil!hoo! traumatic e@periences1 similar results 3ere observe!. 5ecent stress"ul li"e
events 3ere also associate! 3ith 3orse mental health an! health=relate! phsical
"unctionin6. Iach a!!itional recent stress"ul event 3as associate! 3ith an increase o" 1.0
%*+C CI# 0.'1 1.2& unit on the P9SD smptomatolo6 scale1 an increase o" 0.B %0.,1 0.-&
units on the P/E=* !epressive smptoms scale1 an! a !ecrease o" 0.+ %^0.-1 ^0.2& units
on the SJ=' health=relate! phsical "unctionin6 score.
9able 3
+i-ariate association of lifetime trauma e/posure with mental and physical health8
Mo!els to test linearit 6enerall supporte! linear relationships bet3een the traumatic
an! stress"ul event measures an! health status1 in!icatin6 pro6ressive 3orsenin6 o"
phsical or mental health 3ith each a!!itional potentiall traumatic or stress"ul event. An
e@ception 3as the relationship bet3een recent stress"ul events an! P9SD
smptomatolo61 "or 3hich a Fua!ratic mo!el su66este! the increase in P9SD smptoms
accelerate! as the number o" recent stress"ul events increase!. Mo!els that use!
interaction terms to test "or homo6eneit across cohorts in the relationships bet3een the
traumatic an! stress"ul event measures an! health status supporte! homo6eneous
relationships across cohorts %P values "or li4elihoo! ratio tests comparin6 neste! mo!els
3ith an! 3ithout interaction terms ]0.0+&.
9able , presents a series o" multivariate re6ression mo!els e@aminin6 the chan6e in the
ma6nitu!e o" the association o" trauma histor 3ith P9SD smptomatolo6 as t3o
hpothesiKe! me!iators %recent stress"ul events an! current !epressive smptoms& are
a!!e! to the mo!el. In Mo!el 11 3ithout me!iators1 trauma histor remaine! associate!
3ith increase! P9SD smptomatolo6 a"ter a!Austin6 "or !emo6raphic an! socio=
economic characteristics %9able ,1 Mo!el 1&. ?omen reporte! 6reater P9SD
smptomatolo6 than men1 an! 6reater househol! assets 3ere associate! 3ith "e3er
P9SD smptoms. ?hen the number o" recent stress"ul events 3as a!!e! to the mo!el
%9able ,1 Mo!el 2&1 the coe""icient "or trauma 3as attenuate! b ,1C but remaine!
statisticall si6ni"icant1 su66estin6 that recent stress"ul events mi6ht mo!erate part ( but
not all ( o" the relationship bet3een histor o" potentiall traumatic e@periences an!
current P9SD smptoms. ?hen current !epressive smptoms 3ere a!!e! to the mo!el
%9able ,1 Mo!el 3&1 the coe""icient "or trauma 3as attenuate! an a!!itional 20C an! the
coe""icient "or recent stress"ul events 3as attenuate! b 23C1 su66estin6 that current
!epressive smptoms mi6ht mo!erate part ( but not all ( o" the relationships bet3een
trauma1 stress"ul events1 an! current P9SD smptoms.
9able ,
%ulti-ariate model of predictors of P!SD symptomatolo'y8
In a similar set o" neste! mo!els 3ith the SJ=' health=relate! phsical "unctionin6 score
as the outcome1 histor o" potentiall traumatic e@periences 3as associate! 3ith 3orse
health=relate! phsical "unctionin6 a"ter a!Austin6 "or !emo6raphic an! socio=economic
characteristics %9able +1 Mo!el 1&. ?omen ha! 3orse health=relate! phsical "unctionin6
than men1 an! 6reater househol! assets 3ere associate! 3ith improve! health=relate!
phsical "unctionin6. ?hen the number o" recent stress"ul events 3as a!!e! to the mo!el
%9able +1 Mo!el 2&1 the coe""icient "or trauma 3as attenuate! b 20C but remaine!
statisticall si6ni"icant1 su66estin6 that recent stress"ul events mi6ht mo!erate part ( but
not all ( o" the relationship bet3een histor o" potentiall traumatic e@periences an!
current health=relate! phsical "unctionin6. ?hen current !epressive smptoms 3ere
a!!e! to the mo!el %9able +1 Mo!el 3&1 the coe""icient "or trauma 3as attenuate! an
a!!itional ,3C an! the coe""icient "or recent stress"ul events 3as attenuate! b *0C1
su66estin6 that current !epressive smptoms mi6ht mo!erate most or all o" the
relationships bet3een trauma1 stress"ul events1 an! current health=relate! phsical
"unctionin6. 9he "urther a!!ition o" P9SD smptomatolo6 to the mo!el !i! not
substantivel chan6e other coe""icients %9able +1 Mo!el ,&.
9able +
%ulti-ariate model of health-related physical functionin'8
;o to#
Discussion
9his stu! "oun! that 9anKanian a!ults 3ith establishe! /I< in"ection ha! hi6her
e@posure to both chil!hoo! an! li"etime potentiall traumatic e@periences than !i! the
ne3l teste! /I< positive1 ne3l teste! /I< ne6ative1 or communit samples. 9he ne3l
teste! /I< positive an! communit cohorts 3ere similar1 an! those ne3l teste! /I<
ne6ative ha! the lo3est overall li"etime e@posure to potentiall traumatic events. 9hese
"in!in6s are similar to ?estern stu!ies !emonstratin6 hi6her prevalence o" e@posure to
traumatic events amon6 P8?/A. L-M1 L10M1 L23M1 LB3M /o3ever1 this e@cess 3as not !ue
to hi6her prevalence o" chil!hoo! se@ual an! phsical abuse# the reporte! prevalence o"
these e@periences amon6 the cohort 3ith establishe! /I< in"ection %BC an! 2C1
respectivel& 3as lo3er than in man other stu!ies an! 3as not elevate! relative to the
6eo6raphicall matche! a!ult communit cohort. 9he hi6her overall trauma e@posure
amon6 those 3ith establishe! /I< in"ection relative to the communit cohort in this
stu! 3as !ue primaril to hi6her prevalence !urin6 chil!hoo! o" parental alcohol use1
!ru6 use1 "i6htin61 or threats1 an! hi6her prevalence o" loss o" a chil! or spouse. Some o"
these events1 such as chil!hoo! e@periences1 are li4el to have prece!e! /I< in"ection;
others1 such as loss o" a chil! or spouse1 ma partiall re"lect hi6her inci!ence o" /I<
in"ection amon6 spouses or chil!ren. I@posure to potentiall traumatic events in
chil!hoo! is associate! 3ith hi6h ris4 se@ual an! !ru6 use behaviors that increase ris4 o"
acFuirin6 /I<1 so those 3ho e@perience! more chil!hoo! trauma ma have1 throu6h a
histor o" increase! ris4 behaviors1 contracte! /I< earlier in li"e1 thereb placin6 them in
the establishe! /I< in"ection rather than ne3l !ia6nose! /I< cohort. L1,M1 L22M(L2'M.
In bivariate analses1 3e !etermine! that 6reater e@posure to potentiall traumatic events
3as associate! 3ith poorer phsical an! mental health accor!in6 to patient sel"=report
measures. 9here 3as a linear relationship bet3een number o" li"etime potentiall
traumatic events an! P9SD an! !epressive smptom severit1 as 3ell as health=relate!
phsical "unctionin6 scores. Multivariate mo!els con"irme! trauma histor as associate!
3ith increase! P9SD smptom severit. 9he association 3ith trauma 3as attenuate!1 but
not completel e@plaine!1 b recent stress"ul events an! presence o" current !epressive
smptoms. Similarl1 multivariate mo!els o" the association o" li"etime traumatic event
e@posure 3ith health=relate! phsical "unctionin6 !emonstrate! that e@posure to
potentiall traumatic e@periences 3as associate! 3ith 3orse health=relate! phsical
"unctionin6. In this case1 the a!!ition o" recent stress"ul events an! current !epressive an!
P9SD smptoms to the mo!el appeare! to completel e@plain the association1 3hich
su66ests that current mental health smptoms ma mo!erate comple@ relationships
bet3een trauma1 stress1 an! current health=relate! phsical "unctionin6. 9hese "in!in6s
are consistent 3ith previous research 3hich i!enti"ie! associations bet3een trauma
histor an! health=relate! phsical "unctionin6 in P8?/A that 3as partiall or "ull
me!iate! b current mental health in!icators. L31M.
9o !ate1 the maAorit o" sub=Saharan A"rican stu!ies loo4in6 at prevalence o" e@posure to
traumatic events have occurre! in populations e@pose! to lar6e=scale con"lict an!
!isplacement. LB,M1 LB+M Data about the prevalence o" traumatic li"e events in the 6eneral
population in sub=Saharan A"rica or other lo3 income nations are much more limite!.
$ne e@ception is a lon6itu!inal stu! o" South A"rican 3omen 3hich sho3e! that those
3ith a histor o" intimate partner violence ha! a 6reater ris4 o" /I< acFuisition than
those 3ithout. LB,M In a secon! stu! comparin6 trauma histor an! P9SD prevalence
bet3een P8?/A in the >S Deep South an! 9anKania1 one "ourth o" 9anKanian
respon!ents compare! to 3BC o" >S respon!ents reporte! a histor o" se@ual assault; -C
o" >.S. respon!ents ha! a probable !ia6nosis o" P9SD compare! to 22C o" 9anKanian
respon!ents. LB+M ;iven the clear e""ects o" trauma on mental health1 health=relate!
phsical "unctionin61 /I< ris4 behaviors1 an! /I< !isease pro6ression in ?estern1
con"lict=e@pose!1 an! re"u6ee populations1 it is essential to better characteriKe the
prevalence o" e@posure to potentiall traumatic events in P8?/A an! their in"luence on
health in!icators an! other important outcomes1 especiall as access to /I< treatment
pro6rams in sub=Saharan A"rica is rapi!l e@pan!in6.
In the >.S.1 histor o" e@posure to traumatic events is associate! 3ith poor treatment
a!herence1 hi6h ris4 se@ual an! !ru6 use behaviors that increase !isease transmission1
lo3er me!ication a!herence1 an! increase! rates o" pro6ression to AIDS an! mortalit.
L1,M1 L22M(L2'M1 L31M(L3,M Jurther1 in >.S. populations1 e@posure to potentiall traumatic
events appears to have a cumulative e""ect1 in 3hich people 3ith hi6her trauma e@posure
e@perience poorer outcomes1 inclu!in6 lo3er A59 a!herence1 LBBM hi6her virolo6ic
"ailure1 LBBM an! increase! AIDS=relate! an! all=cause mortalit rates. L33M 9hese results
are consistent 3ith the "in!in6s "rom the present stu! that current mental health an!
health=relate! phsical "unctionin6 appeare! to !eteriorate in a linear "ashion 3ith
increasin6 trauma e@posure. Interestin6l1 in one stu! patients 3ith a !ia6nosis o" P9SD
relate! to their /I< !ia6nosis actuall ha! lo3er rates o" suboptimal a!herence to A59.
LB-M Patients 3ith P9SD relate! to potentiall traumatic events other than /I< !ia6nosis
3ere not inclu!e!1 an! it is li4el that the an@iet an! !istress relate! to P9SD1 since
centere! aroun! "ear o" /I< an! !isease pro6ression1 ma contribute to me!ication
a!herence. /o3ever1 in P8?/A 3ho have a !ia6nosis o" P9SD as a result o" an tpe o"
trauma1 A59 a!herence is lo3er; "in!in6s 3hich are in 4eepin6 3ith the bo! o" literature
on P9SD an! A59 a!herence in P8?/A. LB'M(L-0M.
In interpretin6 the results o" this stu!1 it shoul! be note! that e@posure to traumatic
events1 !epressive an! P9SD smptoms1 an! health=relate! phsical "unctionin6 3ere
measure! b sel"=report. 5eportin6 o" prior traumatic events ma have been subAect to
recall bias because most traumatic events occurre! ears prior to the stu! intervie3s1 or
un!er=reportin6 !ue to reluctance to mention !i""icult e@periences. It is possible that
recall o" past events 3as !i""erential in 3as that 3oul! bias some o" the associations
e@amine! in this paper1 "or e@ample i" those 3ith 3orse current mental health 3ere more
li4el to recall !i""icult past e@periences. 9hus this stu! ma have un!erestimate! the
prevalence o" potentiall traumatic events. In a!!ition1 the cross=sectional !esi6n o" the
analses presente! here limits the abilit to ma4e causal in"erences about the
relationships bet3een e@posure to traumatic events an! chan6es in mental health an!
health=relate! phsical "unctionin6. ?e estimate! the prevalence o" trauma in /I<
patients in establishe! me!ical care1 but !i! not inclu!e /I<=in"ecte! in!ivi!uals 3ho
3ere not in care1 3hich ma have le! to an un!erestimation o" the mental health bur!en
amon6 /I<=in"ecte! in!ivi!uals overall. Jinall1 a number o" comparisons are reporte!1
su66estin6 caution in interpretin6 in!ications o" statistical si6ni"icance. $ne notable
stren6th o" the stu! is the inclusion o" a 6eo6raphicall matche! communit cohort;
most previous stu!ies have compare! trauma rates to 6eneral population rates rather than
to rates in the /I<=positive participantsV communities o" ori6in.
$ur "in!in6s su66est that the associations bet3een potentiall traumatic events an!
current mental health an! health=relate! phsical "unctionin6 in P8?/A 3hich have
been observe! in hi6h income countries ma appl in sub=Saharan A"rican populations as
3ell. 9hese results un!erline the importance o" i!enti"in6 an! respon!in6 to trauma
histories 3ithin /I< me!ical care. As access to /I< me!ical care an! antiretroviral
therap continues to e@pan! rapi!l in sub=Saharan A"rica1 "urther research is nee!e! in
the re6ion to con"irm 3hether trauma pre!icts other /I<=relate! behaviors an! outcomes
o" epi!emiolo6ic an! clinical importance1 such as se@ual ris4 behaviors1 en6a6ement in
me!ical care1 me!ication a!herence1 an! mortalit1 as it has in hi6h income countries. At
the same time1 consi!eration must be 6iven no3 to !esi6nin6 /I< clinical pro6rams
capable o" a!!ressin6 pschosocial characteristics that ma enhance or impe!e
en6a6ement in care an! clinical response.
;o to#
,ootnotes
Competin' Interests: 9he authors have !eclare! that no competin6 interests e@ist.
,undin': 9he proAect !escribe! 3as supporte! b 6rant +501M/0-'-+B "rom the
.ational Institute o" Mental /ealth. 9he content is solel the responsibilit o" the authors
an! !oes not necessaril represent the o""icial vie3s o" the .ational Institute o" Mental
/ealth or the .ational Institutes o" /ealth. 9he "un!ers ha! no role in stu! !esi6n1 !ata
collection an! analsis1 !ecision to publish1 or preparation o" the manuscript.
;o to#
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Jurnal ,-
.oc .ci Med. Author manuscript; available in PMC 201& Ma# 1.
Published in nal edited !orm as"
.oc .ci Med. 2012 Ma#; ($ %10' " 1/20)1/2(.
Published online 2012 March A. doi" 10.101A+P.socscimed.2012.01.020
PMCI," PMC&/1*2H0
-IHM.I," -IHM.&AA&0(
Attitudes and beliefs related to HIV1AIDS
in urban reli'ious con're'ations:
+arriers and opportunities for HIV-
related inter-entions
3ic7# -. Eluthenthal1 Ph.,.1 >arti7a Palar1 M.A.1 Peter Mendel1 Ph.,.1 ,avid N.
>anouse1 Ph.,.1 ,ennis N. Corbin1 M...J.1 Ph.,.1 and >athr#n Pit7in ,erose1
Ph.,.1 M.P.H.
Author in!ormation : Cop#ri6ht and 8icense in!ormation :
The publisherYs nal edited version o! this article is available at .oc .ci Med
0o to"
Abstract
/I<=relate! sti6mas have been seen as a barrier to 6reater reli6ious con6re6ation
involvement in /I< prevention an! care in the >nite! States an! else3here. ?e e@plore!
con6re6ational an! communit norms an! attitu!es re6ar!in6 /I<1 se@ualit1 an! !ru6
use throu6h a Fualitative case stu! o" 1, !iverse reli6ious con6re6ations in 8os An6eles
Count1 Cali"ornia bet3een December 200B an! Ma 200'. Data collecte! inclu!e!
semi=structure! intervie3s 3ith +- cler6 an! la lea!ers across the con6re6ations1
structure! observations o" con6re6ational activities1 revie3 o" archival !ocuments1 an! a
Fuestionnaire on con6re6ational characteristics.
Across an! 3ithin con6re6ations1 3e "oun! a 3i!e ran6e o" vie3s to3ar!s /I<1 people
3ith /I<1 an! populations at ris4 "or /I<1 "rom hi6hl Au!6mental an! e@clusionar1 to
Olovin6 the sinner1 not the sin1P to acceptin6 an! a""irmin6. Attitu!es an! norms about
/I<1 homose@ualit1 an! substance abuse appeare! to be relate! to the tpe an! intensit
o" con6re6ational /I<=relate! activities. /o3ever1 even amon6 the hi6her activit
con6re6ations1 3e "oun! a ran6e o" perceptions1 inclu!in6 ones that 3ere sti6matiKin6.
5esults su66est that a""irmin6 norms an! attitu!es are not a prereFuisite "or a
con6re6ation to initiate /I< activities1 a "in!in6 relevant "or /I< service provi!ers an!
researchers see4in6 to en6a6e con6re6ations on this issue. /I< sti6ma=re!uction is not a
prereFuisite "or con6re6ational /I< involvement# both ma occur simultaneousl1 or one
be"ore the other1 an! the !namicall a""ect each other. Strate6ies that are con6ruent
3ith con6re6ationsV current levels o" com"ort an! openness aroun! /I< can themselves
"acilitate a process o" attitu!inal an! normative chan6e.
Keywords: K.A1 HIV1 reli6ion1 sti6ma1 institutional sociolo6#1 urban
con6re6ations1 homose4ualit#1 substance abuse1 interventions
0o to"
I!"#D$C!I#
Sti6ma is a social process that !evalues in!ivi!uals or 6roups possessin6 some
characteristic consi!ere! [un!esirableV b societ %;o""man1 1*B3&. /I< sti6ma (
preAu!ice1 !iscrimination1 an! ne6ative attitu!es to3ar!s in!ivi!uals1 6roups1 an!
communities 3ith or at ris4 "or /I< = has been note! as a challen6e to preventin6 /I<
an! provi!in6 /I< care 3orl!3i!e %/ere41 2002; Par4er H A66leton1 2003; 5ei!path et
al.1 200+&. /I<=relate! sti6ma arises "rom concerns about se@ual promiscuit1
homose@ualit1 an! !ru6 use as 3ell as historicall hi6h mortalit rates %Gerrenber6 et al.1
2002; DiaK et al.1 2001; ;ostin H ?ebber1 1**'; /ere4 et al.1 2003; 8ee et al.1 2002;
Marin1 2003; Mas H Cochran1 1*'-; Sto4es et al.1 1**B; <al!iserri1 2002&.
Jor churches an! other "aith=base! or6aniKations %JG$s&1 reli6ious belie"s that con!emn
homose@ualit an! substance abuse ma contribute to or stren6then these 6eneral sources
o" /I< sti6ma %Schul!en et al.1 200'; Smith et al.1 200+; 9rell et al.1 200'; ?illiams et
al.1 2011&. 0et1 JG$s have been propose! as institutions that coul! be critical to the
communit response to /I<. JG$s have serve! as venues1 participants1 an! or6aniKers o"
/I< testin6 %?hiters et al.1 2010&1 housin6 "or /I< positive in!ivi!uals %Derose1
Domin6ueK et al.1 2010&1 prevention e!ucation %A6ate et al.1 200+; Ger4le=Patton et al.1
2010; ;ri""ith et al.1 2010; 8in!le et al.1 2010&1 an! "oo!1 social support1 pastoral care1
an! other services "or people livin6 3ith /I< %Derose et al.1 2011; GaKant H Goula1
200-; 8eon61 200B&. An! stu!ies o" JG$ e""orts across multiple countries have "oun! that
care an! support activities are consi!ere! tra!itional stren6ths o" JG$s1 even thou6h /I<
prevention e""orts have been hi6hl conteste! 3ithin reli6ious circles1 o"ten !isruptin6
collaborative e""orts %Par4er H Gir!sall1 200+; 9ien!rebeo6o H Gu4@1 200,;
?ol!ehanna et al.1 200+&.
In the >nite! States1 involvement in /I< care an! prevention is not common amon6
JG$s1 an! partnerships bet3een public health entities an! JG$s to a!!ress /I< are rare
%A6ate et al.1 200+&. In one national stu!1 onl 10C o" reli6ious con6re6ations o""ere!
some sort o" health services %9rinitapoli et al.1 200*&; in a surve o" con6re6ations in
Phila!elphia1 onl 11C reporte! an AIDS ministr %Cnaan H Go!!ie1 2001&. Althou6h
sti6ma is o"ten cite! as a barrier to "aith=base! involvement in /I<1 less is 4no3n about
the range o" norms an! attitu!es to3ar! /I< that e@ist in1 amon61 an! aroun!
con6re6ations1 an! ho3 these norms an! attitu!es are relate! to con6re6ational
involvement in /I<=relate! activities.
9o e@plore this issue1 3e con!ucte! a Fualitative case stu! o" 1, urban con6re6ations. In
this paper1 3e e@amine t3o primar Fuestions "rom this stu!# 1& 3hat are the ran6e an!
tpes o" norms an! attitu!es %"rom sti6matiKin6 to a""irmin6& amon6 con6re6ational
lea!ers to3ar!s /I< an! relate! ris4 behaviors %i.e.1 se@ualit an! substance abuse&Y 2&
/o3 !o norms an! attitu!es relate1 i" at all1 to the con6re6ationVs level o" involvement in
/I<=relate! activities or servicesY
Conceptual ,ramewor3
$ur conceptual "rame3or4 !ra3s on our past 3or4 to conceive o" "our "actors
in"luencin6 the involvement o" reli6ious con6re6ations in /I<=relate! activities# norms
an! attitu!es1 or6aniKational structure an! process1 resources1 an! !emo6raphics %Men!el
et al.1 200'1 Derose1 Men!el et al.1 2010&. In this conceptualiKation1 the cate6or o"
Onorms an! attitu!esP is intentionall broa!1 inclu!in6 in!ivi!uall=hel! attitu!es1 belie"s1
values1 4no3le!6e an! co6nitions1 as 3ell as their mani"estations as communit or
con6re6ational norms.
9his paper "ocuses an! e@pan!s on the Onorms an! attitu!esP component o" the
"rame3or4 b unpac4in6 the notion o" sti6ma to3ar!s /I< an! its relationship to other
norms an! attitu!es associate! 3ith con6re6ational involvement in /I< activities. 9he
analsis "urther e@plores ho3 these !imensions at the in!ivi!ual an! collective levels
interact 3ith one another an! 3ith other norms an! attitu!esisuch as perceptions o" /I<
nee! in the con6re6ation or communit1 an! competin6 con6re6ational an! communit
nee!sithat are !escribe! b cler6 an! la lea!ers as in"luencin6 involvement in /I<
activities. Jor e@ample1 some con6re6ations mi6ht have a ne6ative moral appraisal o"
people 3ith /I< as Osinners1P especiall i" associate! 3ith Oun!esirableP characteristics
an! behaviors such as homose@ualit or substance abuse1 but still maintain an acceptin6
stance to3ar!s people 3ith /I< that embo!ies the belie" that all in!ivi!uals are create!
in the ima6e o" ;o!. 5eco6niKin6 a continuum "rom a""irmin6 to sti6matiKin6 valences
on each !imension also permits un!erstan!in6 sti6ma not as a !ichotomous phenomenon
%i.e.1 someone is either sti6matiKe! or not&1 but rather as a continuous variable1 on 3hich
mi!!le positions mi6ht inclu!es moral appraisals o" people 3ith /I< as bein6 not
necessaril better or 3orse than others1 or orientations to3ar! people 3ith /I< that are
acceptin6 or tolerant as oppose! to either 3elcomin6 or reAectin6.
0o to"
%&!H#DS
Case Study %ethods
Durin6 200B(0-1 3e recruite! 1, reli6ious con6re6ations o" !iverse race)ethnicities1
"aiths1 an! siKes in 8os An6eles Count1 Cali"ornia. 9hrou6h !iscussions 3ith communit
e@perts1 our communit a!visor boar! %CAG&1 an! other sources %e.6.1 local "aith=base!
an! /I< resource !irectories&1 3e compile! a list o" '0 con6re6ations potentiall
involve! in /I< activities in three areas most impacte! b /I< in 8os An6eles Count.
?e a!ministere! a brie" telephone screenin6 surve %3ith a response rate o" ''C& to
these con6re6ations. 9he surve inclu!e! Fuestions on /I< an! other health activities
con!ucte! b the con6re6ation an! con6re6ation characteristics. ?ith the CAGVs
assistance1 3e selecte! a purposive sample o" 1, con6re6ations "rom these '01 all o"
3hich ha! some health=relate! activities1 to obtain variation on important issues such
/I<)AIDS activit %inclu!in6 those 3ith ver lo3 or no !iscernable activit&1
race)ethnicit1 !enomination1 reli6ion1 an! siKe. 9hree o" the con6re6ations that 3ere
initiall invite! !ecline! to participate an! 3ere replace! in the sample b similar
con6re6ations. In reco6nition o" the time commitment "or participatin6 in the stu!
%con6re6ations !i! multiple intervie3s1 allo3e! observation o" their activities an!
services1 an! 3ere en6a6e! over several months to a ear&1 each con6re6ation receive! an
unrestricte! "inancial contribution to their or6aniKation %g+00 >SD&.
Data Collection
?e collecte! case stu! !ata usin6 multiple metho!s# in=!epth1 semi=structure!
interie/s 3ith cler6 an! la lea!ers; structure! obserations o" church services an!
health activities; revie3 o" con6re6ational documents1 ne3spaper stories an! other
secon!ar sources; an! a brie"1 sel"=a!ministere! ,uestionnaire on con6re6ational
characteristics. ?ithin each case stu! con6re6ation1 intervie3ees 3ere selecte! base! on
recommen!ations "rom senior cler61 "iel! observations1 an! la lea!ers o" health=relate!
activities or ministries. ?e intervie3e! 3(B in!ivi!uals per con6re6ation 3ho 3ere
i!enti"ie! as 4no3le!6eable about con6re6ation health an! /I<=relate! activities b
senior cler6 an!)or la lea!ers. Ji"t=seven in!ivi!uals across 1, con6re6ations 3ere
intervie3e! "rom December 200B to Ma 200'.
9he intervie3s tpicall laste! 1.+ hours %ran6e 1(, hours& an! 3ere con!ucte! in
person1 in In6lish or Spanish1 b t3o or three members o" the proAect usin6 a semi=
structure! "ormat. Intervie3s 3ere also au!io=recor!e! an! transcribe! verbatim in
In6lish or Spanish. Intervie3ers revie3e! !ra"t intervie3 notes an! transcripts "or
completeness an! accurac. ?e use! structure! "iel! note templates "or the observations
o" reli6ious services1 health an! /I<=relate! activities1 an! local nei6hborhoo! conte@t.
Ithical approval "or the stu! 3as obtaine! "rom the /uman SubAect Protection
Committee at the 5A.D Corporation.
.ualitati-e Data Analysis
Eualitative intervie3s 3ere analKe! usin6 content co!in6 proce!ures to i!enti" themes
relate! to the maAor topics in our conceptual "rame3or4 an! intervie3 protocol %?eber1
1**0& as 3ell as an in!uctive approach to i!enti" ne3 themes that 3ere then a!!e! to the
co!eboo4 %Strauss H Corbin1 1**0; ?eber1 1**0&. 9hemes 3ere hierarchicall structure!1
3ith sub=themes create! as appropriate. /i6her level themes inclu!e! tpes o" /I< an!
other health activities con!ucte! b con6re6ations1 an! the 3as in 3hich the activities
3ere or6aniKe! an! implemente!; con6re6ational an! communit norms an! attitu!es
re6ar!in6 /I<1 homose@ualit1 !ru6 use1 se@ual behavior1 an! health issues in 6eneral;
an! con6re6ational bac46roun! an! !namics more 6enerall %e.6.1 mission1 polit1
membership composition&. Sub=themes 3ere create! as appropriate an! !re3 out
speci"icit 3ithin these broa!er themes. Jor e@ample1 un!er O9pes o" /I< activitiesP1
sub=themes inclu!e! OPrevention an! I!ucationP1 OCare an! SupportP1 an! OA3areness
an! A!vocacP
5esearch team members 3or4e! in pairs usin6 Fualitative te@t mana6ement so"t3are
%Muhr1 200B& to test=co!e1 then "ull co!e1 the intervie3 transcripts1 perio!icall !ouble=
co!in6 transcripts at prescribe! intervals to maintain inter=rater reliabilit1 resolve
!iscrepancies1 an! con"irm emer6ent themes b consensus. Jiel! observations an!
archival !ocuments 3ere use! to provi!e conte@t to the cases an! help in"orm analsis o"
the intervie3 !ata.
!hematic analysis
All Fuotations an! notes relate! to the main co!es o" interest "or this paper %attitu!es
to3ar!s /I<1 homose@ualit1 !ru6 use1 an! se@ual behavior& 3ere revie3e! b 3 o" the
co=authors %5.G1 2P1 2PD&. ?e e@amine! ho3 attitu!es relate! to /I< !isease1 se@ual
behaviors1 an! substance use varie! amon6 the con6re6ations. /ere our interest 3as to
!etermine variations in salience an! ran6e o" attitu!es to3ar!s sub=6roups1 particularl
6as an! lesbians1 se@uall active unmarrie! people an! substance abusers.
In a!!ition1 3e cate6oriKe! the level o" con6re6ational /I< activit as !etermine! b our
previous analsis %Derose et al.1 2011& in terms o"# 1& lo3 /I< activiticon6re6ational
activities are in"reFuent or not tar6ete! speci"icall to /I< %e.6.1 a earl AIDS mass&; 2&
me!ium /I< activitiactivities occur more than once a ear an! ma tar6et /I<1 but
are an e@tension o" 3hat con6re6ations tra!itionall !o1 such as provi!in6 pastoral care to
people 3ith /I<; an! 3& hi6h /I< activitiactivities are "reFuent1 tar6et /I<1 an!
inclu!e multiple tpes o" activities above an! beon! 3hat con6re6ations tra!itionall
!o.
0o to"
"&S$(!S
Con're'ational and Inter-iew Participant Characteristics
9able 1 !escribes 4e characteristics o" the con6re6ations %nD1,& an! intervie3
participants %nD+-&. Selecte! con6re6ations 3ere raciall an! ethnicall varie! an!
inclu!e! 3 primaril Spanish=spea4in6 con6re6ations an! 2 mi@e!=race con6re6ations.
9he also varie! b siKe1 !enomination1 an! reli6ion. All con6re6ations ha! at least some
/I< activit# B 3ere cate6oriKe! as hi6h /I< activit1 , as me!ium /I< activit1 an! , as
lo3 /I< activit. ?e intervie3e! more men than 3omen an! more la lea!ers than
cler6. ?e !i! not collect in"ormation on respon!ent a6e1 but the maAorit appeare! to be
over thirt.
Table 1
Con6re6ation and Intervie= Participant Characteristics
Con're'ational orms and Attitudes towards HIV
5espon!ents e@presse! a 3i!e ran6e o" norms an! attitu!es about /I<1 "rom pro"oun!
sti6ma to "ull acceptance o" people livin6 3ith /I< an! those most at ris4 "or it.
/o3ever1 most con6re6ational participants ( cler6 an! la lea!er ( e@presse!
orientations that "ell in the mi!ran6e o" this continuum.
At the sti6matiKin6 en! o" the continuum1 participants ten!e! to lin4 /I< to sin an!
con!emne! people 3ith /I< "or havin6 en6a6e! in ris4 behaviors that are contrar to
scripture or !octrine. Jor e@ample1 a pastor "rom a Pentecostal %8atino immi6rant&
con6re6ation !escribe! /I< as a Au!6ment "rom ;o!#
5e6ar!in6 the ones that are not a""ecte!1 man believe that AIDS is a Au!6ment "rom
;o!1 an! in "act 3e believe so because I have stu!ie! some about its ori6in an!
everthin6. So itVs ;o!Vs Au!6ment "or all the lasciviousness an! everthin6 else that
e@ists in the 3orl!.
/o3ever1 "e3 participants e@presse! solel Au!6mental attitu!es to3ar!s people 3ith
/I<; instea!1 man invo4e! a call to compassion "or the person 3ith /I<1 o"ten tie! to a
belie" that one shoul! Olove the sinner1 not the sin.P Jor e@ample1 a pastor at a Mainline
Protestant %A"rican American& con6re6ation e@presse! !isapproval o" homose@ualit
to6ether 3ith a "eelin6 o" love "or all humanit1 inclu!in6 people 3ith /I<1 base! on the
i!ea that ;o! is the ultimate authorit#
See1 I !o embrace the homose@ual. Gut1 li4e I sai!1 the li"estle1 an! the moralit o" it1 I
!onVt embrace1 because o" 3hat scripture sasm Gut 3hat I teach the people1 then ;o!
is the Au!6e. /eVll !o the Au!6in6. ?e are to love people. 0ou can love people LintoM the
4in6!om o" ;o!1 but ou canVt hate people into the 4in6!omm.Gecause a person has
AIDS !oes not 6ive ou the ri6ht to hate that person.m
9o3ar!s the more acceptin6 en! o" the continuum1 people 3ho either ha! been personall
a""ecte! b /I< or reco6niKe! that their con6re6ation or communit ha! been a""ecte!
ten!e! to !iscuss /I< in this 3a even 3hile reco6niKin6 that /I< remains an
uncom"ortable topic. A la lea!er "rom a Catholic %A"rican American& con6re6ation note!
that /I< has ha! a ver personal impact on the church communit an! emphasiKe! that it
is a health an! not a moral issue#
I thin4 that 3ithin the church communitmthat some3here alon6 the 3a someone has
been touche! b L/I<M. G that1 I mean it ma be our brother1 it ma be our cousin1
an! 3e have ha! some parishioners 3ho themselves have passe! a3a.itVs not moral
because "or me "rom !a one it:s been a health issue.
A 5abbi "rom a Je3ish %?hite& con6re6ation also !iscusse! /I< as a public health issue1
tin6 his con6re6ationVs concern to bein6 locate! in a communit that is hi6hl a""ecte!
b /I<#
?ell1 L/I< isM an issue in terms o" prevention an! 3eVre concerne! about it 3ith our 4i!s1
3ith our hi6h school 4i!s movin6 "or3ar! that the 4no3 ho3 to protect themselves1 that
the 4no3 3hat sa"e se@ is an! stu""m.but I !onVt 4no3 o" anbo! here 3ho is /I<
positivemas "ar as I 4no31 itVs not a bi6 issue internall. ItVs an issue "or us because 3eVre
part o" a communit 3here itVs a bi6 issue.
Jinall1 at the acceptin6 en! o" the continuum1 a "e3 respon!ents e@presse! attitu!es o"
soli!arit an! a""irmation "or people 3ith /I<. At a Mainline Protestant %mi@e! race&
con6re6ation1 a pastor tal4e! about ho3 ta4in6 a stron6 an! public stance in support o"
people 3ith /I< 3as an important si6nal that these people 3ere 3elcome! at the church#
An! so 3e 4ne3 i" 3e L!isplae! this AIDS smbol publiclMm.that it 3as a 3a o"
sain6 to the communit1 O0ouVre love!.Pm. O?eVre open1 an! 3e love everone. An!
ou 3ill al3as be able to 3al4 in these !oors.P An! thatVs bi6. It 3as1 I thin41 o" a hu6e
an! smbolic importance to the 6a communit an! to the church communit. It 3as
such a 3itness to sam because there are a lot o" churches 3ho 3oul! turn people a3a.
"elationships between Attitudes towards HIV and those towards Se/uality
and Substance Abuse
/I<=relate! attitu!es 3ere closel tie! to se@ual behavior1 particularl amon6
respon!ents 3ith mostl ne6ative attitu!es to3ar!s /I<. 5espon!ents 3ho con!emne!
/I< as a conseFuence o" sin o"ten lin4e! this attitu!e to Au!6ments about homose@ualit1
havin6 multiple se@ual partners1 an! se@ outsi!e o" marria6e1 all o" 3hich the consi!ere!
contrar to scripture or reli6ious !octrine.
Con6re6ational lea!ers 3ho ha! ne6ative attitu!es to3ar!s /I< 3ere li4el to con!emn
homose@ualit. 9he pastor o" a Pentecostal %8atino immi6rant& con6re6ation su66este!
that !octrine prohibitin6 se@ outsi!e o" marria6e an! homose@ualit protecte!
con6re6ants %an! other believers& a6ainst /I<#
I thin4 the church has been an important element 3ithin societ because it has prevente!
a lot o" people "rom becomin6 in"ecte!1 !ue to us not believin6 in promiscuit1 because
3eVre teachin6 our outh the importance o" bein6 consecrate! in that area1 se@uall1 "or
;o!. Also because 3e !onVt have 6a communities. So that has 4ept us a3a "rom /I<.
Some respon!ents !i! not con!emn heterose@ual e@tra=marital se@ as stron6l as the !i!
homose@ualit. ?hile se@ outsi!e o" marria6e an!)or non=mono6am 3ere o"ten
consi!ere! 3ron61 the 3ere also reco6niKe! as problems o" natural human temptation1
an! there"ore "or6ivable.
$n the other han!1 those respon!ents 3ho e@presse! soli!arit 3ith people 3ith /I< an!
3ho tal4e! about /I<=positive in!ivi!uals in an a""irmin6 3a ten!e! to vie3
homose@ualit as part o" human !iversit. $ne Catholic priest in a pre!ominantl 8atino
con6re6ation e@presse! the belie" that people !o not choose to be 6a1 but that itVs part o"
O;o!Vs !esi6nP#
0eah1 3ell1 ouVve 6ot this thin6 3here people sa1 O?ell1 somebo! chooses to be 6a.P
.obo! chooses to be 6a1 thatVs insane. 9hatVs Aust absolutel implausible. 0ou are 6a1
3hether 6eneticall or somethin6 elsem 9hatVs ;o!Vs !esi6n "or ou1 nothin6 3ron6 3ith
that. 9hat:s ;o!Vs ?ill.
A pastor at a Mainline Protestant %mi@e! race& con6re6ation 3ent "urther to state that the
church 3elcomes all people re6ar!less o" se@ual orientation1 an! see4s to counteract the
ne6ative e@periences that 6a an! lesbian con6re6ants e@perience! in previous reli6ious
settin6s#
9oo man 6a an! lesbian persons "eel reAection "rom the church1 especiall churches
theVve 6ro3n up in1 "rom "amil. An! 3e 3ant to create a place 3here the are
3elcome! as a chil! o" ;o!.m ?e have a lot o" recoverin6 Southern Gaptists
herem.an! "ol4s 3ho have been !isen"ranchise!1 either b their "amilies or their church1
or tol! that the canVt come to church anmore1 because theVre not 3orth=because
theVre 6a or lesbian.
Interestin6l1 attitu!es to3ar! con!om use as an /I< prevention strate6 seeme! less
char6e! than attitu!es to3ar!s homose@ualit. A minorit o" respon!ents %3ho 3ere all
Catholic& note! o""icial !enominational policies a6ainst con!om use1 but even amon6
these respon!ents there 3as a 6eneral consensus that teachin6 people about con!oms is
important "or /I< prevention. $ne Catholic la lea!er at an A"rican American
con6re6ation e@presse! this attitu!e#
Con!om use is the bi6 one "or the Catholic Church. An! to be honest 3ith ou1 I !onVt
4no3 3hen theVre 6oin6 to turn thin6s aroun!m.I have sai! the ver "irst thin6 I tal4
about is abstinence1 because reall1 thatVs the onl 100 percentmAn! secon!l1
mono6am. Gut ouVve 6ot to 6om a step "urther b spea4in6 o" con!oms1 because
theVre not 6oin6 to be abstinentmtheVre not 6oin6 to be.
9here 3ere also some respon!ents 3ho "ocuse! on Ohelpin6 people ma4e 6oo! an!
health choicesP concernin6 se@ual behavior1 rather than onl seein6 se@ as permissible
in marria6e. Such attitu!es 3ere apparent even in con6re6ations in 3hich there 3as a
theolo6ical pre"erence "or abstinence outsi!e o" marria6e. A pastor "rom a Mainline
Protestant %A"rican American& con6re6ation !escribe! this O!ual belie"P in both
abstinence an! harm re!uction strate6ies 3hen !escribin6 the counselin6 provi!e! to a
male con6re6ant 3ho ma have ha! se@ual contact 3ith other men in prison#
.o3 the best practice is abstinence1 because ou 4no3 the Gible sas to abstain L"romM
"ornication.mGut IVm Aust ver open 3ith him1 an! he tal4e! to me1 he sai!1 O.o1
5everen! Lname omitte!M1P he sas1 OI havenVt ha! se@ 3ith an 6us in prison.P An! I
sai!1 O?ell1 IVm not 6oin6 to as4 ou 3hat ou !i!. IVm ta4in6 ou at our 3or!1 but IVm
tellin6 ou1 i" ou have ha! se@ 3ith an 6us in prison1 hereVs 3hat ou !omou 6o1
ou 6et teste!1P I sai!1 Oan! ou use con!oms1 at least "or a ear.P
Attitu!es to3ar!s substance an! alcohol use an! abuse 3ere less Au!6mental an! more
varie! than those concernin6 /I< an! se@ual activit outsi!e marria6e. Jor e@ample1 one
pastor at an evan6elical %8atino& con6re6ation lin4e! /I< an! homose@ualit to sin1 but
3hen it came to alcohol1 he sai! OI canVt sho3 anbo! in the Gible 3here it sas1
[Drin4in6 alcohol is a sin1V ou see.P A pastor at a Mainline Protestant %A"rican
American& con6re6ation tal4e! about the hi6h salience o" substance abuse issues "or the
con6re6ation because o" con6re6antsV o3n a!!iction problems or those o" "rien!s an!
"amil#
Some Lparticipants in the substance abuse ministrM come in Aust to sit in because theVve
6ot a "amil member thatVs on !ru6s an! theVve been an enabler to help them sta on
!ru6sm.a lot o" them !o come Aust "or that because rarel 3ill ou "in! anbo! in this
countr to!amthat !onVt 4no3 somebo! thatVs been touche! b !ru6s an! alcohol.
HIV Attitudes by HIV Acti-ity (e-el
?e "oun! that norms an! attitu!es varie! b /I< activit level. 9he most common
activities in the lo3 activit con6re6ations 3ere /I< e!ucation 3ithin more 6eneral
health=relate! 3or4shops1 cler6 or la lea!er participation in e@ternall sponsore!
/I<)AIDS trainin6s or 3or4shops1 an! occasional pastoral care "or people 3ith /I<.
Amon6 lo3=activit con6re6ations1 t3o main themes 3ere !ominant# sti6ma an! lo3
priorit. 5e6ar!in6 sti6ma1 as one pastor "rom an evan6elical %8atino& con6re6ation
!escribe! con6re6antsV attitu!es as1 OItVs more li4e1 [$h man1 ou have AIDS1V li4e
cooties. [0ou have cooties1 oh1 6et a3a1 3e !onVt 3ant to 6et it.V I thin4 thatVs 3here itVs
"rom.P Participants in the lo3=activit con6re6ations also 3ere more li4el to vie3
homose@ualit as a sin an! to ma4e stron6 statements in "avor o" se@ual abstinence until
marria6e. /I< 3as also re6ar!e! as a lo3 priorit in these con6re6ations. Jor e@ample1 a
priest "rom a Catholic %8atino& con6re6ation commente!# OI 3oul! sa L/I< isM "ar !o3n
on the pec4in6 or!er. .o3 3hether it shoul! be is1 o" course1 another Fuestion.P A la
lea!er "rom a Pentecostal %8atino& con6re6ation state!1 O?ell to be honest1 I havenVt even
ta4en it into account1 I havenVt even consi!ere! it.P A pastor "rom the same con6re6ation
o""ere! more conte@t "or this sentiment 3hen he sai!1 OI thin4 itVs more o" a priorit "or
us to have a shelter "or sa1 the unemploe!1 o" 3hich there are man.P
Jor me!ium activit con6re6ations the most common /I< activities 3ere /I< e!ucation
via 3or4shops or printe! materials1 health "airs that inclu!e /I< issues1 tal4in6 to
con6re6ants about /I< prevention %i.e. con!oms1 abstinence&1 an! support o" AIDS
service or6aniKations. A common theme "or these con6re6ations 3as trans"ormation "rom
a position o" "ear about /I< to un!erstan!in6 an! acceptance. 9his 3as best illustrate! b
a pastor "rom a mainline Protestant %A"rican American& con6re6ation 3hen he !escribe!
ho3 e!ucation aroun! /I< positivel chan6e! con6re6ational an! !enominational
attitu!es#
I mean1 the taboos that 3e 3ere !ealin6 3ith alon6 that line1 an! thatVs 3hat I li4en AIDS
to Aust "or m o3n point o" re"erence1 ho3 a"rai! 3e 3ere to even voice that that 3as
3hat 3as 6oin6 on because 3e ha! bou6ht into the theolo6 o" the reli6ious ri6ht an! the
conservatives1 an! the evan6elicals 3hose theolo6ical posture 3as such that it 3as ;o!Vs
con!emnation upon the sin o" homose@ualit1 an! then e!ucation helpe! us un!erstan!.
9he statistics helpe! us un!erstan! that1 ou 4no31 that it 33asnVt the casem
In the me!ium=activit con6re6ations1 3e "oun! attitu!es to3ar!s homose@ualit to be
more varie! an! nuance!. ?hile some respon!ents 3ithin me!ium=activit con6re6ations
reporte! !iscom"ort 3ith homose@ualit1 the attitu!es o" other con6re6ants an! cler6 in
such con6re6ations coul! be best characteriKe! as acceptin6. Jor instance1 one la lea!er
"rom a Je3ish %?hite& con6re6ation observe! that OMost o" the con6re6ation is "ine 3ith
Lhomose@ualitM ( un!erstan!s that the current scienti"ic thin4in6 about ho3 bein6 6a is
not a choice1 but somethin6 that ouVre born 3ith.P
In some me!ium=activit con6re6ations1 cler6 an! la lea!ers encoura6e! abstinence1
but "elt that people shoul! protect themselves "rom pre6nanc an! se@uall transmitte!
in"ections i" the coul! not sustain abstinence. A pastor "rom a Mainline Protestant
%A"rican American& con6re6ation e@presse! a tpical sentiment#
?ell1 ou 4no31 the pre"erence "or me in terms o" as I teach an! !eal 3ith 4i!s is
abstinence. Gut the realit is that theVre 6oin6 to be !ealin6 3ith their libi!os an! so ou
have to !eal 3ith sa"e se@1 the precautionar an! preventive actions that the can ta4e.
Amon6 hi6h activit con6re6ations the most common activities 3ere /I< e!ucation via
3or4shops or printe! materials1 material or spiritual support "or people 3ith /I<1 support
to AIDS service or6aniKations1 sermons or 3orship services !e!icate! to AIDS1
participatin6 in 3al4s an! marches "or AIDS1 an! en6a6in6 in public a!vocac an!
sti6ma re!uction on behal" o" people 3ith /I<. /i6h=activit con6re6ations 3ere
characteriKe! b substantial acceptance an! support o" people livin6 3ith /I< an!)or
reco6nition o" /I< as an important issue. 9hese con6re6ations ten!e! to have lon6er
histories o" 3or4in6 on the issue an! more visible 6roups o" 6a an! lesbian con6re6ants
than !i! the lo3= an! me!ium=activit con6re6ations. In man o" these hi6h=activit
con6re6ations1 /I<=positive in!ivi!uals coul! be open about their /I< status. A rabbi o"
a Je3ish %pre!ominantl ?hite& con6re6ation note! that the support that the con6re6ation
sho3e! "or people 3ith /I< meant that people 3ith /I< 3ere com"ortable bein6 open
about their status#
In ever sin6le ne3sletter1 3e have a bi6 a! that promotes the ne@t !ates "or our /I<
support 6roup. 0ou 4no31 an! 3eVre reall open about it. An! I tal4 about it. An! 3e
have people 3ho are the visible "acem theVre open about their status.
/o3ever1 in some o" the hi6h=activit con6re6ations1 /I< sti6ma 3as still an issue. Jor
instance1 one la lea!er at a Catholic %A"rican American& con6re6ation state! that
con6re6ants sometimes believe! that 6ettin6 involve! 3ith /I< activities meant that
others 3oul! thin4 the have /I<#
9hatVs one o" the problems is recruitin6 members1 6ettin6 people to become members o"
the AIDS ministr. 9heVre either a"rai! that people are 6oin6 to thin4 the have it. I
6uess thatVs 3hat it is.
In some hi6h=activit con6re6ations1 reli6ious belie"s con!emnin6 homose@ualit an!)or
homose@ual behavior still !ominate! the social norms. Some o" the hi6h=activit
con6re6ations also emphasiKe! abstinence "rom heterose@ual se@ outsi!e marria6e an!
!ru6 use. 5e6ar!less o" these vie3s1 ho3ever1 there 3ere numerous statements in "avor
o" con!om use to prevent /I<. Jor instance1 one la lea!er "rom a Catholic %A"rican
American& con6re6ation remar4e! that in !iscussin6 the nee! "or con!oms to prevent
/I<1 she tells cler61 OI am not tal4in6 about prevention o" li"e. IVm tal4in6 about
prevention o" !eath.P In another hi6h=activit con6re6ation 3ith a stron6 emphasis on
se@ual abstinence be"ore marria6e1 a pastor 3as e@plicit in his conversations 3ith outh
about the nee! to use con!oms to prevent pre6nanc an! /I< i" the are not 6oin6 to be
abstinent.
In summar1 lo3=activit con6re6ations appeare! consistentl to consi!er /I< to be a
sti6matiKin6 !isease an! a lo3 priorit. Jor con6re6ations at the me!ium /I< activit
level1 !iscom"ort 3ith /I< an! associate! behaviors coe@iste! 3ith belie"s about the
importance o" a!!ressin6 /I<1 3hich sometimes resulte! "rom e@perience 3ith
con6re6ation=base! /I< activities an!)or people 3ith /I<1 an! sometimes seeme! to be
the impetus "or startin6 activities. 9he con6re6ations 3ith hi6her levels o" activit ten!e!
more "reFuentl to e@press attitu!es on the a""irmin6 %less sti6matiKin6& en! o" the /I<
attitu!e continuum1 but also sho3e! more !iversit b !isplain6 attitu!es across the
continuum1 inclu!in6 ones that 3ere sti6matiKin6. 9his 6roup o" con6re6ations %o" hi6her
levels o" /I< activit& 3as also the most !iverse in terms o" pre!ominant race)ethnicit
an! !enomination.
0o to"
DISC$SSI#
"an'e of HIV attitudes
?e "oun! a 3i!e ran6e o" norms an! attitu!es to3ar!s /I<1 people 3ith /I<1 an! people
at ris4 "or /I< amon6 con6re6ational lea!ers1 "rom hi6hl sti6matiKin6 to acceptin6 an!
a""irmin6. Alon6 this attitu!inal continuum1 our respon!ents o""ere! theolo6ical1 cultural1
an! practical Austi"ication "or their vie3s. 0et1 similar to others %2hosrovani et al.1 200';
8in!le et al.1 2010&1 3e also "oun! !iverse1 an! o"ten con"lictin61 vie3s to3ar!s people
livin6 3ith /I< %an! ris4 behaviors associate! 3ith /I<& 3ithin the same con6re6ation.
9he attitu!inal !iversit amon6st an! 3ithin con6re6ations about /I< su66est that a
priori Au!6ments about con6re6ational interest in /I< activities base! on !enomination1
theolo61 an! !emo6raphics coul! be too constrainin6.
?e also "oun! that attitu!es an! norms to3ar!s /I<1 homose@ualit1 an! substance abuse
appeare! relate! to the type an! intensity o" con6re6ational /I< activities. ?hile 3e
cannot !etermine 3hether attitu!es in"luence! the activities1 activities in"luence! the
attitu!es1 or 3hether both 3ere in"luence! b some thir! variable1 such as the presence o"
openl 6a members in the con6re6ation1 the histories o" con6re6ational involvement
provi!e! b our in"ormants su66este! a tren! o" increasin6 /I< activit as
con6re6ational norms an! attitu!es move! "rom sti6matiKin6 to a""irmin6. /o3ever1 the
hetero6eneit in these orientations amon6 con6re6ations 3ith hi6h activit su66ests that
norms an! attitu!es are not the onl !rivers o" activit. Jurther1 there ma be a bi=
!irectional relationshipinorms an! attitu!es ma a""ect the level an!)or tpe o" /I<
activit1 3hile con6re6ational involvement in /I< activit ma lea! to a shi"t in
con6re6antsV norms an! attitu!es over time throu6h such processes as social learnin6
%Gan!ura1 1*--& an! !issonance re!uction %Jestin6er1 1*+-&.
&n'a'in' con're'ations in HIV pre-ention; care; and support
>n!erstan!in6 the ran6e o" attitu!es an! some o" their sources can be use! to i!enti"
appropriate con6re6ational activities1 particularl "or e@ternal entities such as health
!epartments or AIDS service or6aniKations that see4 to en6a6e con6re6ations. Jor
e@ample1 lac4 o" 4no3le!6e about /I< seroprevalence an! transmission behaviors is
li4el to be easier to chan6e than attitu!es to3ar!s homose@ualit1 6iven !octrinal
positions on the subAect. Jor 6reater success in en6a6in6 reli6ious con6re6ations1 /I<
practitioners or researchers coul! be6in 3ith con6re6ations that have some !e6ree o"
positive attitu!inal orientation to3ar!s /I< or relate! behaviors)6roups1 "or e@ample1
con6re6ations 3ith openl 6a an! lesbian members.
0et1 it ma not be necessar to 3ait "or Oa""irmin6P attitu!es to !evelop in!epen!entl in
con6re6ations prior to attemptin6 to en6a6e them in /I<=relate! activities. 5ather1
strate6ies that are con6ruent 3ith con6re6ationsV current levels o" com"ort an! openness
aroun! /I<1 such as provi!in6 in"ormation materials an! spea4ers1 can themselves
"acilitate a process o" attitu!e chan6e. Jor e@ample1 3e "oun! that a number o" our case
stu! con6re6ations ha! sponsore! /I< testin6 events %Derose et al.1 2011&1 o"ten as part
o" lar6er health "airs. It is possible that con6re6ations 3ith less a""irmin6 attitu!es 3oul!
embrace /I< testin6 more rea!il than other prevention strate6ies %such as con!om
promotion&1 3hich in turn coul! help OnormaliKeP /I< as a health rather than a moral
issue1 as others have su66este! %2och H Gec4le1 200B; Mc.eal H Per4ins1 200-&.
5e!ucin6 sti6ma 3ithin reli6ious con6re6ation is important1 as sti6matiKin6 /I<1
homose@ualit1 an! substance abuse ma !irectl harm at=ris4 populations %Gro3n et al.1
2003&. A recent stu! su66ests that interventions aime! at re!ucin6 /I< sti6ma in
con6re6ations ma be "easible an! acceptable 3hen tailore! to the speci"ic reli6ious an!
cultural conte@t1 even in con6re6ations 3here there is visible /I< sti6ma present
%8in!le et al.1 2010&. Jurther1 in vie3 o" JG$sV moral authorit1 broa! reach1 an! abilit
to in"luence attitu!es1 sti6ma re!uction is an area in 3hich JG$ lea!ers coul! have an
especiall stron6 impact. Previous literature has reveale! that the e@periences o" cler6 or
la lea!ers 3ith /I< e!ucation1 4no3in6 someone 3ith /I<1 or perceivin6 it as a
problem in the communit1 are all relate! to the !evelopment o" "aith=base! /I<
activities 3ithin con6re6ations %A6ate et al.1 200+; Chin et al.1 200+; /ernnn!eK et al.1
200-&. 5ecent research su66ests that even across con6re6ations 3ith similar structural
an! institutional "eatures1 this in!ivi!ual e@perience an! a6enc o" the cler6 ma lea! to
ver !i""erent responses to /I< %Cunnin6ham et al.1 2011&.
In a!!ition1 it ma be possible "or some con6re6ations to a!!ress sti6ma !irectl an!
in"luence con6re6ational norms an! attitu!es. 5esearch in ;hana in!icate! that hearin6 a
lea!er spea4 about /I<)AIDS ha! a substantial e""ect on con6re6antsV provision o"
support to people 3ith /I< %GaKant H Goula1 200-&. Stu!ies else3here %e.6.1 Jamaica1
9rini!a!1 9anKania1 >6an!a1 9anKania1 Mala3i& have "oun! that JG$s can move "rom
"osterin6 to !issua!in6 sti6ma throu6h trainin6s that increase 4no3le!6e an!
un!erstan!in6 o" /I< amon6 cler6 an! con6re6ations members1 increase! personal
contact bet3een con6re6ational lea!ers an! people 3ith /I<1 creatin6 social spaces that
are supportive to people 3ith /I<1 an! !irect involvement o" people 3ith /I< in
con6re6ational prevention1 care an! a!vocac e""orts %Campbell et al.1 2010; ;enrich H
Grath3aite1 200+; /art3i6 et al.1 200B; Muturi1 200'; $tolo4=9an6a et al.1 200-;
9rinitapoli1 200B&.
.evertheless1 our stu! su66ests that /I< involvement is not %an! nee! not be& a linear
outcome o" /I< sti6ma=re!uction# both ma occur simultaneousl1 or one ma occur
be"ore the other1 !namicall a""ectin6 each other. I" the 6oal o" initiatin6 con6re6ational
/I< activities is to trans"orm ho3 the issue is a!!resse! over time 3ithin a""ecte!
communities1 then it is important to i!enti" startin6 places "or a 3i!e variet o"
con6re6ation settin6s1 especiall those that ma appear less visibl open to /I<
involvement. In!ee!1 a stren6ths=oriente! service mo!el that "ocuses on 3hat reli6ious
or6aniKations can !o 3ith their current resources1 versus a mo!el that emphasiKes 3hat is
missin6 "rom con6re6ational e""orts1 ma better empo3er cler6 to con"ront /I< !espite
i!eolo6ical resistance %5amireK=Johnson et al.1 2011&.
Attitu!inal "actors must be ta4en into account to6ether 3ith conte@tual an! institutional
"eatures o" con6re6ations to e@plain ho3 an! 3h the 6et involve! in /I< 3or4.
Althou6h this paper !i! not a!!ress conte@tual an! institutional "actors !irectl1
international stu!ies have note! ho3 JG$sV involvement in /I< has been helpe! or
hin!ere! b conte@tual or institutional "actors %;arcia H Par4er1 2011; Murra et al.1
2011&. In the >nite! States1 recent 3or4 across !iverse ethnic 6roups an! reli6ious
settin6s su66ests that bein6 communit=oriente! an! embracin6 social en6a6ement ma
be more important than theolo6ical orientation in e@plainin6 con6re6ational involvement
3ith /I< %Julton1 2011&1 an! ma be a "acilitator to overcomin6 ne6ative attitu!es an!
norms to3ar!s /I< such as "ear o" in"ection an! concerns about social acceptabilit
%Chin et al.1 2011&.
$ur approach to this topic has a number o" limitations. ?e use! purposive samplin61 thus
our results are not representative o" con6re6ations in 8os An6eles Count or o" the "aith
tra!itions or !enominations o" 3hich the are members. Jurther1 our small sample siKe
an! Fualitative approach !o not permit comparisons across "aith tra!itions or
!enominations. 0et1 our samplin6 approach allo3e! us to !ocument a 3i!e ran6e o"
norms an! attitu!es about /I<1 homose@ualit1 an! !ru6 use amon6 con6re6ations an! to
consi!er ho3 these attitu!es are relate! to one another1 an! ho3 the relate to /I<
con6re6ational activities. In a!!ition1 o" necessit1 our results !epen! on sel"=reports that
ma be subAect to sociall !esirable respon!in6. /o3ever1 our comparative case stu!
!esi6n incorporatin6 in=!epth intervie3s 3ith multiple cler6 an! con6re6ants1
observations o" multiple events an! services1 an! !ata collection over multiple months "or
each con6re6ation allo3e! "or !evelopin6 the rapport necessar "or elicitin6 perspectives
on sensitive topics an! "or trian6ulatin6 "in!in6s on perspectives "rom a variet o"
sources.
Jin!in6s "rom this research su66est that con6re6ational /I< activities are possible
!espite the presence o" /I<=relate! sti6ma an! ma in "act contribute to the "urther
re!uction o" sti6ma over time. Attitu!es an! norms un!oubte!l a""ect JG$ 3illin6ness
to a!!ress /I< an!1 alon6 3ith institutional an! conte@tual "actors1 the particular /I<=
relate! activities the un!erta4e. /o3ever1 trin6 to assess 3hether JG$s have the
Ori6htP attitu!e ma ultimatel be a less use"ul en!eavor than !eterminin6 the 4in!s o"
activities that are suitable entr points "or a!!ressin6 /I< in the conte@t o" a particular
con6re6ationVs culture1 belie" sstem1 an! resources.
Je observed that positive and ne6ative attitudes about HIV and
behavioral ris7 !or HIV ran6e across and =ithin urban reli6ious
con6re6ations.
Con6re6ations =ith substantial HIV<related sti6ma can still contribute
to HIV prevention and care eOorts.
Nn6a6in6 con6re6ations in some HIV<related activities ma# increase
aZrmin6 attitudes to=ards people =ith and at<ris7 !or HIV.
HIV sti6ma should be vie=ed continuousl# rather than dichotomousl#.
0o to"
Ac3nowled'ments
9he Eunice 7ennedy Shrier .ational Institute o" Chil! /ealth an! /uman Development
supporte! this stu! %.IC/D ( 6rant Z501 /D0+01+0 ( PI# Derose&. 9his articleVs
contents are solel the responsibilit o" the authors an! !o not necessaril represent the
o""icial vie3s o" .IC/D. 9he authors than4 the stu!Vs Communit A!visor Goar! 3ho
has provi!e! e@cellent 6ui!ance an! counsel throu6hout the stu!1 especiall 5ev. Dr.
Cl!e ?. $!en1 5ev. Michael Mata1 Delis AleAan!ro1 Deborah $3ens Collins1 2eesha
Johnson1 Mario PereK1 5ev. Chris Ponnet1 5t. 5ev. Chester 9alton1 an! 5ichar! Xal!ivar.
?e also than4 the 1, case stu! con6re6ations an! their lea!ers. Jor con"i!entialit
reasons1 the are not name!.
0o to"
,ootnotes
PublisherIs Disclaimer: 9his is a PDJ "ile o" an une!ite! manuscript that has been
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revie3 o" the resultin6 proo" be"ore it is publishe! in its "inal citable "orm. Please note
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