AIDS and Behavior

, Volume 22, Issue 10, pp 3155–3165 | Cite as

Incidence and Persistence of Depression Among Women Living with and Without HIV in South Africa: A Longitudinal Study

  • Georgina Spies
  • Elisabete Castelon Konkiewitz
  • Soraya Seedat


Depression and trauma are common among women living with HIV. This is the first study to track the longitudinal course of depression and examine the relationship between depression and trauma over time among women in South Africa. HIV-infected and uninfected women (N = 148) were assessed at baseline and one year later. Results of a path analysis show the multi-directional and entwined influence of early life stress, other life-threatening traumas across the lifespan, depression and PTSD over the course of HIV. We also observed higher rates of depressive symptomatology and more persistent cases among infected women compared to uninfected women, as well as a more consistent and enduring relationship between childhood trauma and depression among women living with HIV. The present study is unique in documenting the course of untreated depression and PTSD in women with and without HIV infection with a high prevalence of early childhood trauma.


HIV Depression PTSD Childhood trauma 



This work is supported by the South African Research Chair in PTSD awarded to S Seedat and hosted by Stellenbosch University, funded by the DST and administered by NRF and the Faculty of Medicine and Health Sciences, Stellenbosch University (Deputy Dean’s strategic fund for postdoctoral fellows and sub-committee C postdoctoral fellowship). Additional research support was provided by a CFAR grant awarded to S Seedat [P30-AI036214] Professor Martin Kidd from the department of Statistics and Actuarial Sciences of Stellenbosch University provided statistical assistance.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical Approval

All procedures involving human participants were in accordance with the ethical standards for the institutional review board and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by the Health Research Ethics Committee (HREC) of Stellenbosch University, South Africa (HREC #: N07/07/153).

Informed Consent

Informed consent was obtained from all individual participants included in the study. No personal identifying information is included in the manuscript.


  1. 1.
    Statistics South Africa. Mid-year population estimates. Vol. 2017. 2016.Google Scholar
  2. 2.
    Bloomfield GS, Khazanie P, Morris A, Rabadan-Diehl C, Benjamin LA, Murdoch D, et al. HIV and noncommunicable cardiovascular and pulmonary diseases in low- and middle-income countries in the ART era: what we know and best directions for future research. J Acquir Immune Defic Syndr. 2014;67(Suppl 1):S40–53.CrossRefGoogle Scholar
  3. 3.
    Adebamowo CA, Casper C, Bhatia K, Mbulaiteye SM, Sasco AJ, Phipps W, et al. Challenges in the detection, prevention, and treatment of HIV-associated malignancies in low- and middle-income countries in Africa. J Acquir Immune Defic Syndr. 2014;67(Suppl 1):S17–26.CrossRefGoogle Scholar
  4. 4.
    Abas M, Ali GC, Nakimuli-Mpungu E, Chibanda D. Depression in people living with HIV in sub-Saharan Africa: time to act. Trop Med Int Health. 2014;19(12):1392–6.CrossRefGoogle Scholar
  5. 5.
    Colibazzi T, Hsu TT, Gilmer WS. Human immunodeficiency virus and depression in primary care: a clinical review. Prim Care Companion J Clin Psychiatry. 2006;8(4):201–11.CrossRefGoogle Scholar
  6. 6.
    Bing EG, Burnam MA, Longshore D, Fleishman JA, Sherbourne CD, London AS, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry. 2001;58(8):721–8.CrossRefGoogle Scholar
  7. 7.
    Myer L, Smit J, Roux L Le, Parker S, Stein DJ, Seedat S. Common mental disorders among HIV-infected individuals in South Africa: prevalence, predictors, and validation of brief psychiatric rating scales. AIDS Patient Care STDs. 2008;22(2):147–58. Scholar
  8. 8.
    Olley BO, Seedat S, Stein DJ. Persistence of psychiatric disorders in a cohort of HIV/AIDS patients in South Africa: a 6-month follow-up study. J Psychosom Res. 2006;61(4):479–84.CrossRefGoogle Scholar
  9. 9.
    Stein DJ, Seedat S, Herman A, Moomal H, Heeringa SG, Kessler RC, et al. Lifetime prevalence of psychiatric disorders in South Africa. Br J Psychiatry. 2008;192(2):112–7.CrossRefGoogle Scholar
  10. 10.
    Gibbie T, Mijch A, Ellen S, Hoy J, Hutchison C, Wright E, et al. Depression and neurocognitive performance in individuals with HIV/AIDS: 2-year follow-up. HIV Med. 2006;7(2):112–21. Scholar
  11. 11.
    Judd F, Komiti A, Chua P, Mijch A, Hoy J, Grech P, et al. Nature of depression in patients with HIV/AIDS. Aust N Z J Psychiatry. 2005;39(9):826–32.CrossRefGoogle Scholar
  12. 12.
    Kinyanda E, Nakasujja N, Levin J, Birabwa H, Mpango R, Grosskurth H, et al. Major depressive disorder and suicidality in early HIV infection and its association with risk factors and negative outcomes as seen in semi-urban and rural Uganda. J Affect Disord. 2017;212:117–27.CrossRefGoogle Scholar
  13. 13.
    Kinyanda E, Weiss HA, Levin J, Nakasujja N, Birabwa H, Nakku J, et al. Incidence and persistence of major depressive disorder among people living with HIV in Uganda. AIDS Behav. 2017;21(6):1641–54.CrossRefGoogle Scholar
  14. 14.
    Olatunji BO, Mimiaga MJ, O’Cleirigh C, Safren SA. Review of treatment studies of depression in HIV. Top HIV Med. 2006;14(3):112–24.PubMedGoogle Scholar
  15. 15.
    Wright E, Brew B, Arayawichanont A, Robertson K, Samintharapanya K, Kongsaengdao S, et al. Neurologic disorders are prevalent in HIV-positive outpatients in the Asia-Pacific region. Neurology. 2008;71(1):50–6.CrossRefGoogle Scholar
  16. 16.
    Kagee A, Saal W, De Villiers L, Sefatsa M, Bantjes J. The prevalence of common mental disorders among South Africans seeking HIV testing. AIDS Behav. 2017;21(6):1511–7.CrossRefGoogle Scholar
  17. 17.
    Ammassari A, Antinori A, Aloisi MS, Trotta MP, Murri R, Bartoli L, et al. Depressive symptoms, neurocognitive impairment, and adherence to highly active antiretroviral therapy among HIV-infected persons. Psychosomatics. 2004;45(5):394–402.CrossRefGoogle Scholar
  18. 18.
    Kacanek D, Jacobson DL, Spiegelman D, Wanke C, Isaac R, Wilson IB. Incident depression symptoms are associated with poorer HAART adherence: a longitudinal analysis from the Nutrition for Healthy Living study. J Acquir Immune Defic Syndr. 2010;53(2):266–72.CrossRefGoogle Scholar
  19. 19.
    Lima VD, Geller J, Bangsberg DR, Patterson TL, Daniel M, Kerr T, et al. The effect of adherence on the association between depressive symptoms and mortality among HIV-infected individuals first initiating HAART. AIDS. 2007;21(9):1175–83.CrossRefGoogle Scholar
  20. 20.
    Mayston R, Kinyanda E, Chishinga N, Prince M, Patel V. Mental disorder and the outcome of HIV/AIDS in low-income and middle-income countries: a systematic review. AIDS. 2012;26(Suppl 2):S117–35.CrossRefGoogle Scholar
  21. 21.
    Tegger MK, Crane HM, Tapia KA, Uldall KK, Holte SE, Kitahata MM. The effect of mental illness, substance use, and treatment for depression on the initiation of highly active antiretroviral therapy among HIV-infected individuals. AIDS Patient Care STDS. 2008;22(3):233–43.CrossRefGoogle Scholar
  22. 22.
    Burack JH, Barrett DC, Stall RD, Chesney MA, Ekstrand ML, Coates TJ. Depressive symptoms and CD4 lymphocyte decline among HIV-infected men. JAMA. 1993;270(21):2568–73.CrossRefGoogle Scholar
  23. 23.
    Cook JA, Grey D, Burke J, Cohen MH, Gurtman AC, Richardson JL, et al. Depressive symptoms and AIDS-related mortality among a multisite cohort of HIV-positive women. Am J Public Health. 2004;94(7):1133–40.CrossRefGoogle Scholar
  24. 24.
    Ickovics JR, Hamburger ME, Vlahov D, Schoenbaum EE, Schuman P, Boland RJ, et al. Mortality, CD4 cell count decline, and depressive symptoms among HIV-seropositive women: longitudinal analysis from the HIV Epidemiology Research Study. JAMA. 2001;285(11):1466–74.CrossRefGoogle Scholar
  25. 25.
    Leserman J. Role of depression, stress, and trauma in HIV disease progression. Psychosom Med. 2008;70(5):539–45.CrossRefGoogle Scholar
  26. 26.
    Vlassova N, Angelino AF, Treisman GJ. Update on mental health issues in patients with HIV infection. Curr Infect Dis Rep. 2009;11(2):163–9.CrossRefGoogle Scholar
  27. 27.
    Leserman J. HIV disease progression: depression, stress, and possible mechanisms. Biol Psychiatry. 2003;54(3):295–306.CrossRefGoogle Scholar
  28. 28.
    Arseniou S, Arvaniti A, Samakouri M. HIV infection and depression. Psychiatry Clin Neurosci. 2014;68(2):96–109.CrossRefGoogle Scholar
  29. 29.
    Sherr L, Clucas C, Harding R, Sibley E, Catalan J. HIV and depression—a systematic review of interventions. Psychol Health Med. 2011;16(5):493–527.CrossRefGoogle Scholar
  30. 30.
    Andersson N, Cockcroft A, Shea B. Gender-based violence and HIV: relevance for HIV prevention in hyperendemic countries of southern Africa. AIDS. 2008;22(Suppl. 4):73–86.CrossRefGoogle Scholar
  31. 31.
    Jewkes R, Penn-Kekana L, Levin J, Ratsaka M, Schrieber M. Prevalence of emotional, physical and sexual abuse of women in three South African provinces. S Afr Med J. 2001;91(5):421–8.PubMedGoogle Scholar
  32. 32.
    Jewkes R, Levin J, Mbananga N, Bradshaw D. Rape of girls in South Africa. Lancet. 2002;359(9303):319–20.CrossRefGoogle Scholar
  33. 33.
    Kalichman SC, Simbayi LC. Sexual assault history and risks for sexually transmitted infections among women in an African township in Cape Town, South Africa. AIDS Care. 2004;16(6):681–9.CrossRefGoogle Scholar
  34. 34.
    Davis SK. The relationship between HIV, maternal childhood sexual abuse survival, and parental sexual communication among African American women 18-24. J Health Care Poor Underserved. 2017;28(2S):24–32.CrossRefGoogle Scholar
  35. 35.
    Fang L, Chuang D-M, Lee Y. Adverse childhood experiences, gender, and HIV risk behaviors: results from a population-based sample. Prev Med Rep. 2016;4:113–20.CrossRefGoogle Scholar
  36. 36.
    Whetten K, Reif S, Toth M, Jain E, Leserman J, Pence BW. Relationship between trauma and high-risk behavior among HIV-positive men who do not have sex with men (MDSM). AIDS Care. 2012;24(11):1453–60.CrossRefGoogle Scholar
  37. 37.
    Leserman J, Whetten K, Lowe K, Stangl D, Swartz MS, Thielman NM. How trauma, recent stressful events, and PTSD affect functional health status and health utilization in HIV-infected patients in the South. Psychosom Med. 2005;67(3):500–7.CrossRefGoogle Scholar
  38. 38.
    Leserman J, Pence B, Whetten K, Mugavero M, Thielman N, Swartz M, et al. Relation of lifetime trauma and depressive symptoms to mortality in HIV. Am J Psychiatry. 2007;164(11):1707–13. Scholar
  39. 39.
    Gillespie CF, Nemeroff CB. Early life stress and depression. Childhood trauma may lead to neurobiologically unique mood disorders. Curr Psychiatr. 2005;4(10):15–30.Google Scholar
  40. 40.
    Negele A, Kaufhold J, Kallenbach L, Leuzinger-Bohleber M. Childhood trauma and its relation to chronic depression in adulthood. Depress Res Treat. 2015;2015:650804.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Pena CJ, Kronman HG, Walker DM, Cates HM, Bagot RC, Purushothaman I, et al. Early life stress confers lifelong stress susceptibility in mice via ventral tegmental area OTX2. Science. 2017;356(6343):1185–8.CrossRefGoogle Scholar
  42. 42.
    Herman AA, Stein DJ, Seedat S, Heeringa SG, Moomal H, Williams DR. The South African Stress and Health (SASH) study: 12-month and lifetime prevalence of common mental disorders. S Afr Med J. 2009;99(5):339–44.PubMedPubMedCentralGoogle Scholar
  43. 43.
    Malan-Muller S, Hemmings SM, Spies G, Kidd M, Fennema-Notestine C, Seedat S. Shorter telomere length—a potential susceptibility factor for HIV-associated neurocognitive impairments in South African women. PLoS ONE. 2013;8(3):e58351.CrossRefGoogle Scholar
  44. 44.
    Spies G, Ahmed-Leitao F, Fennema-Notestine C, Cherner M, Seedat S. Effects of HIV and childhood trauma on brain morphometry and neurocognitive function. J Neurovirol. 2016;22(2):149–58.CrossRefGoogle Scholar
  45. 45.
    Spies G, Fennema-Notestine C, Cherner M, Seedat S. Changes in cognitive function in women with HIV infection and early life stress. AIDS Care. 2017;29(1):14–23.CrossRefGoogle Scholar
  46. 46.
    Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59(Suppl. 20):22–33.PubMedPubMedCentralGoogle Scholar
  47. 47.
    Radloff SF. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1(3):385–401.CrossRefGoogle Scholar
  48. 48.
    Gray MJ, Litz BT, Hsu JL, Lombardo TW. Psychometric properties of the life events checklist. Assessment. 2004;11(4):330–41.CrossRefGoogle Scholar
  49. 49.
    Davidson JRT, Book SW, Colket JT, Tupler LA, Roth S, David D, et al. Assessment of a new self-rating scale for post-traumatic stress disorder. Psychol Med. 1997;27(1):153–60.CrossRefGoogle Scholar
  50. 50.
    Bernstein DP, Stein JA, Newcomb MD, Walker E, Pogge D, Ahluvalia T, et al. Development and validation of a brief screening version of the childhood trauma questionnaire. Child Abuse Negl. 2003;27(2):169–90.CrossRefGoogle Scholar
  51. 51.
    Faul F, Erdfelder E, Buchner A, Lang A-G. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods. 2009;41(4):1149–60.CrossRefGoogle Scholar
  52. 52.
    Pickett KE, Wilkinson RG. Inequality: an underacknowledged source of mental illness and distress. Br J Psychiatry. 2010;197(6):426–8.CrossRefGoogle Scholar
  53. 53.
    Wilkinson RG. The impact of inequality: how to make sick societies healthier. New York: New York Press; 2005.Google Scholar
  54. 54.
    Shea A, Walsh C, Macmillan H, Steiner M. Child maltreatment and HPA axis dysregulation: relationship to major depressive disorder and post traumatic stress disorder in females. Psychoneuroendocrinology. 2005;30(2):162–78.CrossRefGoogle Scholar
  55. 55.
    Meyer-Lindenberg A. Social neuroscience and mechanisms of risk for mental disorders. World Psychiatry. 2014;13(2):143–4.CrossRefGoogle Scholar
  56. 56.
    Syed SA, Nemeroff CB. Early life stress, mood, and anxiety disorders. Chronic Stress: Thousand Oaks; 2017. p. 1.Google Scholar
  57. 57.
    Patel V, Kleinman A. Poverty and common mental disorders in developing countries. Bull World Health Organ. 2003;81(8):609–15.PubMedPubMedCentralGoogle Scholar
  58. 58.
    van Os J, Kenis G, Rutten BP. The environment and schizophrenia. Nature. 2010;468(7321):203–12.CrossRefGoogle Scholar
  59. 59.
    Yang BZ, Zhang H, Ge W, Weder N, Douglas-Palumberi H, Perepletchikova F, et al. Child abuse and epigenetic mechanisms of disease risk. Am J Prev Med. 2013;44(2):101–7.CrossRefGoogle Scholar
  60. 60.
    Wilkinson PO, Goodyer IM. Childhood adversity and allostatic overload of the hypothalamic-pituitary-adrenal axis: a vulnerability model for depressive disorders. Dev Psychopathol. 2011;23(4):1017–37.CrossRefGoogle Scholar
  61. 61.
    Duman RS. Neural plasticity: consequences of stress and actions of antidepressant treatment. Dialogues Clin Neurosci. 2004;6(2):157–69.PubMedPubMedCentralGoogle Scholar
  62. 62.
    Liu W, Ge T, Leng Y, Pan Z, Fan J, Yang W, et al. The role of neural plasticity in depression: from hippocampus to prefrontal cortex. Neural Plast. 2017;2017:6871089.PubMedPubMedCentralGoogle Scholar
  63. 63.
    Clark US, Cohen RA, Sweet LH, Gongvatana A, Devlin KN, Hana GN, et al. Effects of HIV and early life stress on amygdala morphometry and neurocognitive function. J Int Neuropsychol Soc. 2012;18(4):657–68.CrossRefGoogle Scholar
  64. 64.
    Pence BW, Mugavero MJ, Carter TJ, Leserman J, Thielman NM, Raper JL, et al. Childhood trauma and health outcomes in HIV-infected patients: an exploration of causal pathways. J Acquir Immune Defic Syndr. 2012;59(4):409–16.CrossRefGoogle Scholar
  65. 65.
    Vaiserman AM. Epigenetic programming by early-life stress: evidence from human populations. Dev Dyn. 2015;244(3):254–65.CrossRefGoogle Scholar
  66. 66.
    Williams LM, Debattista C, Duchemin AM, Schatzberg AF, Nemeroff CB. Childhood trauma predicts antidepressant response in adults with major depression: data from the randomized international study to predict optimized treatment for depression. Transl Psychiatry. 2016;6:e799.CrossRefGoogle Scholar
  67. 67.
    Kaplan MJ, Klinetob NA. Childhood emotional trauma and chronic posttraumatic stress disorder in adult outpatients with treatment-resistant depression. J Nerv Ment Dis. 2000;188(9):596–601.CrossRefGoogle Scholar
  68. 68.
    National Institute of Mental Health. Major depression among adults. Vol. 2017. 2015.Google Scholar
  69. 69.
    Spijker J, de Graaf R, Bijl RV, Beekman ATF, Ormel J, Nolen WA. Determinants of persistence of major depressive episodes in the general population. Results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS). J Affect Disord. 2004;81(3):231–40.CrossRefGoogle Scholar
  70. 70.
    Spies G, Seedat S. Depression and resilience in women with HIV and early life stress: does trauma play a mediating role? A cross-sectional study. BMJ Open. 2014;4.CrossRefGoogle Scholar
  71. 71.
    Freeman M, Nkomo N, Kafaar Z, Kelly K. Mental disorder in people living with HIV/AIDS in South Africa. S Afr J Psychol. 2008;38(3):489–500. Scholar
  72. 72.
    De Santis JP, Gonzalez-Guarda RM, Vasquez EP. Psychosocial and cultural correlates of depression among Hispanic men with HIV infection: a pilot study. J Psychiatr Ment Health Nurs. 2012;19(10):860–9.CrossRefGoogle Scholar
  73. 73.
    Fonseca MG, Bastos FI. Twenty-five years of the AIDS epidemic in Brazil: principal epidemiological findings, 1980-2005. Cad Saude Publica. 2007;23(Suppl 3):S333–44.CrossRefGoogle Scholar
  74. 74.
    Malee KM, Mellins CA, Huo Y, Tassiopoulos K, Smith R, Sirois PA, et al. Prevalence, incidence, and persistence of psychiatric and substance use disorders among mothers living with HIV. J Acquir Immune Defic Syndr. 2014;65(5):526–34.CrossRefGoogle Scholar
  75. 75.
    Barreto IC, Viegas P, Ziff EB, Konkiewitz EC. Animal models for depression associated with HIV-1 infection. J Neuroimmune Pharmacol. 2014;9(2):195–208.CrossRefGoogle Scholar
  76. 76.
    Del Guerra FB, Fonseca JL, Figueiredo VM, Ziff EB, Konkiewitz EC. Human immunodeficiency virus-associated depression: contributions of immuno-inflammatory, monoaminergic, neurodegenerative, and neurotrophic pathways. J Neurovirol. 2013;19(4):314–27.CrossRefGoogle Scholar
  77. 77.
    Rivera-Rivera Y, Vazquez-Santiago FJ, Albino E, Sanchez MD, Rivera-Amill V. Impact of depression and inflammation on the progression of HIV disease. J Clin Cell Immunol. 2016;7(3):423.CrossRefGoogle Scholar
  78. 78.
    Andersen SL, Tomada A, Vincow ES, Valente E, Polcari A, Teicher MH. Preliminary evidence for sensitive periods in the effect of childhood sexual abuse on regional brain development. J Neuropsychiatry Clin Neurosci. 2008;20(3):292–301.CrossRefGoogle Scholar
  79. 79.
    Brown AS, Susser ES. Prenatal nutritional deficiency and risk of adult schizophrenia. Schizophr Bull. 2008;34(6):1054–63.CrossRefGoogle Scholar
  80. 80.
    Heijmans BT, Tobi EW, Stein AD, Putter H, Blauw GJ, Susser ES, et al. Persistent epigenetic differences associated with prenatal exposure to famine in humans. Proc Natl Acad Sci USA. 2008;105(44):17046–9.CrossRefGoogle Scholar

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Authors and Affiliations

  1. 1.South African Research Chairs Initiative (SARChI), PTSD Program, Department of PsychiatryStellenbosch UniversityCape TownSouth Africa
  2. 2.Faculdade de Ciências Médicas e da SaúdeUniversidade Federal da Grande DouradosDouradosBrazil

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