1. Post-traumatic stress, depression, alcohol use and HIV/AIDS risk among Angolan soldiers Charles R. Drew University of Medicine and Science & the Angolan Armed Forces

2. Collaborators United States: Eric G Bing; Karen G Cheng, Daniel J Ortiz, Ricardo Ovalle-Bahamón Charles R. Drew University of Medicine and Science, Los Angeles Charles R. Drew University of Medicine and Science, Los Angeles Angola: Col. Francisco Ernesto, Col. Francisco João de Deus Angolan Armed Forces, Luanda Angolan Armed Forces, Luanda Funding: National Institute of Mental Health (R01-MH64883-01), US Department of Defense (GC-3482-132-01-009)

3. Background Poor mental health and alcohol use are associated with poor sexual decision- making (e.g., Kelly, et al., 1995; Strathdee, et al., 1998; Thompson, Kao &, Thomas, 2005) Poor mental health and alcohol use are associated with poor sexual decision- making (e.g., Kelly, et al., 1995; Strathdee, et al., 1998; Thompson, Kao &, Thomas, 2005) Post-conflict militaries have unique HIV prevention needs Post-conflict militaries have unique HIV prevention needs –Impact of war on mental health –Role of alcohol  Coping mechanism  Increased strength in fighting

4. Angola 27-year civil war ended in 2002 27-year civil war ended in 2002 Emphasizing HIV prevention now while the infection rate still low (3.7%; UNAIDS, 2006 ) Emphasizing HIV prevention now while the infection rate still low (3.7%; UNAIDS, 2006 )

5. Goals of study 1)Assess frequency of post-traumatic stress, depression and alcohol use among soldiers 2)Assess HIV-related risk 3)Assess relationship between mental health and alcohol use and HIV risk

6. Procedure Randomly selected soldiers from 12 military bases in the capital and in the northern and southern regions Randomly selected soldiers from 12 military bases in the capital and in the northern and southern regions Interviewed by trained civilian interviewers Interviewed by trained civilian interviewers Conducted Feb 2005 – May 2005 Conducted Feb 2005 – May 2005

7. Procedure Dimensions assessed were Dimensions assessed were Mental Health Mental Health  War-related traumatic events  Post-traumatic stress (Impact of Event Scale-Rev)  Depression (MHI-5) Alcohol  AUDIT: Problem drinking  Alcohol use before sex (past month) HIV/AIDS risk  Number of partners (past 3 months)  Sex with occasional or commercial partners (past 3 months)  STI symptoms (past year)

8. Characteristics of sample 568 men (total sample) 568 men (total sample) Average age = 28.9 years Average age = 28.9 years Rank Rank  Privates 33.5%  Sergeants 59.5%  Officers 7.0% Average number of years in military = 10.6 Average number of years in military = 10.6  97% were enlisted during civil war

9. Characteristics of sample Average years of education = 6.0 Average years of education = 6.0 Cultural groups Cultural groups  Ovimbundo 37.5%  Kimbundo 30.9%  Bakongo 8.0%  Other 23.6% Married = 27.6% Married = 27.6% Have children = 81.3% Have children = 81.3%

10. Mental health Number of traumatic events None1-23-56+21.7%21.7%47.0%9.7% Witnessed death of friends 58% Witnessed mutilation of friends 40% Witnessed military execution 51% Experienced severe physical injury 20%

11. Mental health  Both measures were used continuously in multivariate analyses Post-traumatic stress PTSD (≥32) Not PTSD 19.9%80.1% Depression Depressed (≤52) Not depressed 12.3%87.7%

12. Alcohol use Choice of Alcohol BeerWineSpiritsHome-brewed51.7%50.4%29.0%17.6% AUDIT Mild/No drinking Problem drinking (> 8) 65.0%35.0% Alcohol before sex in past month NeverSometimes/Always84.4%15.6%

13. Indicators of HIV/AIDS risk Number of partners 0 (past 3 months) 1 2 3+ 3+10.2%47.3%25.0%17.5% Had sex with occasional partner or CSW (past 3 months) 17.5% Had STI symptom(s) in past year 16.5%

14. Analyses Hierarchical mixed linear/logistic models* Outcomes: Outcomes:  number of partners (log) past 3 mo.  sex with occasional or commercial partner past 3 mo.  STI symptoms past year Predictors Predictors  Sample characteristics  Mental health (traumatic events, post-traumatic stress, depression)  Alcohol use (alcohol before sex) * To account for nesting of participants in bases

15. Predictors of number of sexual partners (log) in past 3 months Coeff.p Has children -0.0004ns Number of traumatic events 0.004ns Post-traumatic stress (10 pt increase) 0.01ns Depression (10 pt increase) 0.007ns Alcohol before sex 0.13<.001

16. Predictors of sex with occasional or commercial partner (past 3 months) Odds Ratio p Conf. Int. Married 0.72 0.72ns0.38-1.36 Has children 0.58 0.58ns0.31-1.09 Rank Privates Privates Sergeants Sergeants Officers Officers 1.00 1.00 0.76 0.76 4.39 4.39ns<.010.41-1.261.66-11.64 Number of traumatic events 1.15 1.15ns0.98-1.35 Post-traumatic stress (10 pt. incr.) 1.23 1.23<.051.001-1.04 Depression (10 pt incr.) 1.03 1.03ns0.98-1.01 Alcohol before sex 3.96 3.96<.0010.14-0.44

17. Predictors of STI symptoms (past year) Odds Ratio p Conf. Int. Married 1.75 1.75<.051.04-2.97 Rank Privates Privates Sergeants Sergeants Officers Officers 1.00 1.00 0.74 0.74 0.67 0.67nsns 0.44-1.22 0.44-1.22 0.99-1.99 0.99-1.99 Number of traumatic events 1.09 1.09ns 0.94-1.26 0.94-1.26 Post-traumatic stress (10 pt increase) 1.13 1.13ns 0.95-1.37 0.95-1.37 Depression (10 pt incr.) 1.14 1.14<.05 0.77-0.98 0.77-0.98 Alcohol before sex 2.00 2.00<.05 1.05-3.34 1.05-3.34

18. Summary Problematic alcohol use consistently predicted increase in HIV/AIDS risk among soldiers Problematic alcohol use consistently predicted increase in HIV/AIDS risk among soldiers Other predictors were poor mental health, higher rank, and being married Other predictors were poor mental health, higher rank, and being married

19. Implications Post-conflict militaries in resource-limited countries face unique challenges Post-conflict militaries in resource-limited countries face unique challenges  Very few providers trained in mental health or substance abuse Need creative solutions Need creative solutions  Structural interventions & policy changes  E.g., reduce accessibility to alcohol near base  HIV prevention designed for higher ranks and married people  Mental health?

20. Contact us Karen Cheng kacheng@cdrewu.edu Eric Bing eric.g.bing@gmail.com