Quality of Life Research

, Volume 22, Issue 8, pp 2073–2084 | Cite as

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

  • Tracy L. GardEmail author
  • Donald R. Hoover
  • Qiuhu Shi
  • Mardge H. Cohen
  • Eugene Mutimura
  • Adebola A. Adedimeji
  • Kathryn Anastos



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


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


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


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


Quality of life Post-traumatic stress disorder HIV Women Rwanda 



Center for Epidemiological Studies-Depression Scale


Highly active antiretroviral therapy


Human immunodeficiency virus


Health-related quality of life


Harvard Trauma Questionnaire


Persons living with HIV


Post-traumatic stress disorder


Quality of life


Rwandan Women’s Interassociation Study and Assessment


Short form-21


  1. 1.
    Human Rights Watch. (1999). Leave none to tell the story: Genocide in Rwanda. New York: Human Rights Watch.Google Scholar
  2. 2.
    Karekezi, U., Nshimiyimana, A., & Mutamba, B. (2004). Localizing justice: Gacaca courts in post-genocide Rwanda. In E. Stover & H. M. Weinstein (Eds.), My neighbor, my enemy: Justice and community in the aftermath of mass atrocity (pp. 69–84). Cambridge: University Press.CrossRefGoogle Scholar
  3. 3.
    Degni-Segui, R. (1996). Question of the violation of human rights and fundamental freedoms in any part of the world, with particular reference to colonial and other dependent countries and territories. Special Rapporteur of the Commission on Human Rights.
  4. 4.
    Donovan, P. (2002). Rape and HIV/AIDS in Rwanda. Lancet, 360, s17–s18.PubMedCrossRefGoogle Scholar
  5. 5.
    Supervie, V., Halima, Y., & Blower, S. (2010). Assessing the impact of mass rape on the incidence of HIV in conflict-affected countries. AIDS, 24, 2841–2847.PubMedCrossRefGoogle Scholar
  6. 6.
    Pham, P., Weinstein, H., & Longman, T. (2004). Trauma and PTSD symptoms in Rwanda: Implications for attitudes toward justice and reconciliation. Journal of the American Medical Association, 292(5), 602–612.PubMedCrossRefGoogle Scholar
  7. 7.
    Cohen, M., Fabri, M., Cai, X., Shi, Q., Hoover, D., Binagwaho, A., et al. (2009). Prevalence and predictors of posttraumatic stress disorder and depression in HIV-infected and at-risk Rwandan women. Journal of Women’s Health, 18(11), 1783–1791.PubMedCrossRefGoogle Scholar
  8. 8.
    Zraly, M., Rubin-Smith, J., Betancourt, T. (2011). Primary mental health care for survivors of collective sexual violence in Rwanda. Global Public Health, 6, 257–270.Google Scholar
  9. 9.
    Cohen, M. H., d’Adesky, A., & Anastos, K. (2005). Women in Rwanda: Another world is possible. JAMA, 294(5), 613–615.PubMedCrossRefGoogle Scholar
  10. 10.
    Hays, R., & Morales, L. (2001). The RAND-36 measure of health-related quality of life. Annals of Medicine, 33, 350–357.PubMedCrossRefGoogle Scholar
  11. 11.
    Hays, R., Cunningham, W., Sherbourne, C., Wilson, I., Wu, A., Cleary, P., et al. (2000). Health-related quality of life in patients with human immunodeficiency virus infection in the United States: Results from the HIV cost and services utilization study. American Journal of Medicine, 108, 714–722.PubMedCrossRefGoogle Scholar
  12. 12.
    Lubeck, D., & Fries, J. (1992). Changes in quality of life among persons with HIV infection. Quality of Life Research, 1, 359–366.PubMedCrossRefGoogle Scholar
  13. 13.
    Liu, C., Johnson, L., Ostrow, D., Silvestre, A., Visscher, B., & Jocobson, L. P. (2006). Predictors of lower quality of life in the HAART era among HIV-infected men. Journal of Acquired Immune Deficiency Syndrome, 42, 470–477.CrossRefGoogle Scholar
  14. 14.
    Fan, A. P., Kuo, H. C., Kao, D. Y., Morisky, D. E., & Chen, Y. A. (2011). Quality of life and needs assessment on people living with HIV and AIDS in Malawi. AIDS Care, 23, 287–302.PubMedCrossRefGoogle Scholar
  15. 15.
    Louwagie, G., Bachmann, M., Meyer, K., Booysen, F., Fairall, L., & Heunis, C. (2007). Highly active antiretroviral treatment and health related quality of life in South African adults with human immunodeficiency virus infection: A cross-sectional analytical study. BMC Public Health, 7(244), 1–10.Google Scholar
  16. 16.
    Morineau, G., Vun, M. C., Barennes, H., Wolf, R. C., Song, N., Prybylski, D., et al. (2009). Survival and quality of life among HIV-positive people on antiretroviral therapy in Cambodia. AIDS Patient Care and STDS, 23, 669–677.PubMedCrossRefGoogle Scholar
  17. 17.
    Wouters, E., Meulemans, H., Van Rensburg, H., Heunis, J., & Mortelmans, D. (2007). Short-term physical and emotional health outcomes of public sector ART in the Free State province of South Africa. Quality of Life Research, 16, 1461–1471.PubMedCrossRefGoogle Scholar
  18. 18.
    Guan, B., Deng, Y., Cohen, P., & Chen, H. (2011). Relative impact of axis I mental disorders on quality of life among adults in the community. Journal of Affective Disorders, 131, 293–298.PubMedCrossRefGoogle Scholar
  19. 19.
    Beard, C., Weisberg, R. B., & Keller, M. B. (2010). Health-related quality of life across the anxiety disorders: Findings from a sample of primary care patients. Journal of Anxiety Disorders, 24, 559–564.PubMedCrossRefGoogle Scholar
  20. 20.
    Adewuya, A., Afolabi, M., Ola, B., Ogundele, O., Ajibare, A., Oladipo, B., et al. (2008). Relationship between depression and quality of life in persons with HIV infection in Nigeria. International Journal of Psychiatry in Medicine, 38(1), 43–51.PubMedCrossRefGoogle Scholar
  21. 21.
    Sherbourne, C., Hays, R., Fleishman, J., Vitiello, B., Magruder, K., Bing, E., et al. (2000). Impact of psychiatric conditions on health-related quality of life in persons with HIV infection. American Journal of Psychiatry, 157, 248–254.PubMedCrossRefGoogle Scholar
  22. 22.
    Leserman, J., Whetten, K., Lowe, K., Stangl, D., Swartz, M. S., & Thielman, N. M. (2005). How trauma, recent stressful events, and PTSD affect functional health status and health utilization in HIV-infected patients in the South. Psychosomatic Medicine, 67, 500–507.PubMedCrossRefGoogle Scholar
  23. 23.
    Bozzette, S., Hays, R., Berry, S., Kanouse, D., & Wu, A. (1995). Derivation and properties of a brief health status assessment instrument for use in HIV disease. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 8, 253–265.PubMedCrossRefGoogle Scholar
  24. 24.
    Safren, S. A., Hendriksen, E. S., Smeaton, L., Celentano, D. D., Hosseinipour, M. C., Barnett, R., et al. (2012). Quality of life among individuals with HIV starting antiretroviral therapy in diverse resource-limited areas of the world. AIDS Behavior, 16, 266–277.Google Scholar
  25. 25.
    Bono, C., Ried, L., Kimberlin, C., & Vogel, B. (2007). Missing data on the Center for Epidemiologic Studies Depression Scale: A comparison of 4 imputation techniques. Research in Social Administration Pharmacology, 3, 1–27.CrossRefGoogle Scholar
  26. 26.
    Radloff, L. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401.CrossRefGoogle Scholar
  27. 27.
    American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.Google Scholar
  28. 28.
    Mollica, R., McDonald, L., Massagli, M., & Silove, D. (2004). Measuring trauma, measuring torture. Cambridge: Harvard Program in Refugee Trauma.Google Scholar
  29. 29.
    Beckerman, N. L., & Auerbach, C. (2010). Post-traumatic stress disorder and HIV: A snapshot of co-occurrence. Social Work in Health Care, 49, 687–702.PubMedCrossRefGoogle Scholar
  30. 30.
    Kalichman, S., Rompa, D., & Cage, M. (2000). Distinguishing between overlapping somatic symptoms of depression and HIV disease in people living with HIV-AIDS. The Journal of Nervous and Mental Disease, 188(10), 662–670.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2012

Authors and Affiliations

  • Tracy L. Gard
    • 1
    • 2
    Email author
  • Donald R. Hoover
    • 3
  • Qiuhu Shi
    • 4
  • Mardge H. Cohen
    • 5
  • Eugene Mutimura
    • 6
  • Adebola A. Adedimeji
    • 7
    • 8
  • Kathryn Anastos
    • 8
    • 9
  1. 1.Department of Psychiatry and Behavioral SciencesAlbert Einstein College of MedicineBronxUSA
  2. 2.Department of Psychiatry and Behavioral SciencesMontefiore Medical CenterBronxUSA
  3. 3.Statistics and Institute for Health, Health Care Policy and Aging ResearchRutgers UniversityNew BrunswickUSA
  4. 4.New York Medical CollegeValhallaUSA
  5. 5.Department of Medicine, Stroger (Cook County) HospitalRush UniversityChicagoUSA
  6. 6.Women’s Equity in Access to Care and Treatment (WE-ACTx)Kigali Health InstituteKigaliRwanda
  7. 7.Centre for Public Health SciencesAlbert Einstein College of MedicineBronxUSA
  8. 8.Department of Epidemiology and Population HealthAlbert Einstein College of MedicineBronxUSA
  9. 9.Department of MedicineMontefiore Medical CenterBronxUSA

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