Improvement in post traumatic stress & depressive symptoms in HIV-infected Rwandan women on antiretroviral therapy Mardge H. Cohen, Mary Fabri, Xiaotao Cai, Agnes Binagwaho, Qiuhu Shi, Kathryn Anastos Rwandan Women’s Interassociation Sudy and Assement (RWISA)

Methods RWISA, a prospective observational cohort study of effectiveness and toxicity of ART in women, including survivors of genocidal rape, enrolled 710 HIV-infected and 226 uninfected women in 2005. At 6 month study visits, interviewers collect medical & psychosocial data to assess HIV disease progression and ART use Trained research staff administered the Harvard Trauma Questionnaire (HTQ) and Center for Epidemiologic Studies Depression Scale (CES-D). Participants with PTSD scores > 2 and CES-D scores >=16 were considered to have PTSD and depressive symptoms. Trained trauma counselors provide support for participants as needed.

Results % HIV+ women on ART Baseline CESD and PTSD scores HIV- HIV+ CES-D Mean 19.8 23.1 < 0.001 >16 61.1 79.8 <0.001 >27 20.0 28.9 0.020 PTSD Mean 2.39 2.29 0.112 >2 64% 57% 0.099 % HIV+ women on ART Visit 1 2 3 4 % 0 47 57 65 Change in Rate of PTSD and Depressive Symptoms Visit 1-4 in RWISA Depressive Symptoms PTSD Symptoms 1 2 3 4 Visit 1 2 3 4

Predictors of Reduced CESD and PTSD scores from Visit 1 to Visit 4* For the whole cohort --HIV was the only significant predictor for reduced CESD scores --Uninfected women and women with more traumatic events had significantly greater reductions in PTSD scores from visits 1 to 4. For HIV infected women -- those with lower CD4 cell counts were more likely to have more reductions in CESD and PTSD scores. --Those experiencing genocidal rape had greater reductions in PTSD scores. -- ART was not a significant predictor of reduced scores. *Controlling for age, marriage, HIV status, education, rape status during genocide, & trauma events, we used mixed models to solve for fixed effects using CESD and PSTD as the dependent variable.

Conclusions Providing a safe, understanding, and helpful community of care reduces PTSD and depression symptoms, though depression symptoms are more persistent. Administration of HTQ and access to trauma counselors provided a therapeutic environment Structured interviews gave women opportunity to tell their trauma stories and impact of that experience was greater in those with more trauma events/severe trauma. Although depressive symptoms and PTSD were reduced over 18 months, especially in women with HIV and those with a history of rape and more traumatic events, these conditions remained prominent among the entire cohort. One out of two women at visit 4 still reported depressive symptoms and almost one of four reported PTSD symptoms. Clinical care settings should address these conditions to reduce morbidity among women with HIV.