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Journal of Aective Disorders Reports 4 (2021) 100094
Contents lists available at ScienceDirect
Journal of Aective Disorders Reports
journal homepage: www.elsevier.com/locate/jadr
Research Paper
Childhood trauma, major depressive disorder, suicidality, and the
modifying role of social support among adolescents living with HIV in rural
Uganda
Scholastic Ashaba
a , ∗
, Christine E. Cooper-Vince
b
, Samuel Maling
a
, Emily N. Satinsky
a , c
,
Charles Baguma
a
, Dickens Akena
d
, Denis Nansera
a
, Francis Bajunirwe
a
, Alexander C. Tsai
a , c , e , f
a
Mbarara University Science and Technology, Mbarara, Uganda
b
Départment de Psychiatrie, Universitié de Genève, Switzerland
c
Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
d
Department of Psychiatry, Makerere College of Health Sciences, Makerere, Uganda
e
Harvard Medical School, Boston, MA, USA
f
Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
Keywords:
Adolescents
Adverse childhood experiences
HIV
Mental health
Sub-Saharan Africa
Uganda
Trauma
Background: Childhood trauma is associated with mental health problems among adolescents living with HIV
(ALHIV) in sub-Saharan Africa, but little is known about potential moderating factors.
Methods: We enrolled 224 ALHIV aged 13–17 years and collected information on childhood trauma, major de-
pressive disorder, and suicidality. We used modied multivariable Poisson regression to estimate the association
between the mental health outcome variables and childhood trauma, and to assess for eect modication by
social support.
Results: Major depressive disorder had a statistically signicant association with emotional abuse (adjusted rela-
tive risk [ARR] 2.57; 95% CI 1.31–5.04; P = 0.006) and physical abuse (ARR 2.16; 95% CI 1.19–3.89; P = 0.01).
The estimated association between any abuse and major depressive disorder was statistically signicant among
those with a low level of social support (ARR 4.30; 95% CI 1.64–11.25; P = 0.003) but not among those with a
high level of social support (ARR 1.30; 95% CI 0.57–2.98; P = 0.52). Suicidality also had a statistically signicant
association with emotional abuse (ARR 2.03; 95% CI 1.05–3.920; P = 0.03) and physical abuse (ARR 3.17; 95%
CI 1.60–6.25.; P = 0.001), but no dierences by social support were noted.
Limitations: Corporal punishment is used widely in schools and homes as a form of discipline in Uganda; this
cultural practice could have biased reporting about physical abuse.
Conclusions: Childhood trauma is associated with poor mental health among ALHIV, but its eects may be
moderated by social support. More research is needed to develop social support interventions for ALHIV with
adverse childhood experiences for improved mental health outcomes.
1. Introduction
In 2016, there were 2.1 million adolescents living with HIV (AL-
HIV) worldwide, 73,000 of whom were living in Uganda constitut-
ing 4% of the worldwide population of ALHIV ( Slogrove et al., 2017 ;
UNAIDS, 2018 ). Additionally, there were 1.4 million people living with
HIV in Uganda in 2016, and 160,000 of these were young people aged
15–24 years ( UNAIDS, 2018 ) . Although availability of antiretroviral
∗ Corresponding author.
E-mail address: sashaba@must.ac.ug (S. Ashaba).
therapy (ART) has enabled children perinatally infected with HIV to
grow into adolescence and young adulthood ( Brady et al., 2010 ), AL-
HIV in sub-Saharan Africa face myriad HIV-related challenges includ-
ing orphanhood, HIV stigma, and discrimination that aect their abil-
ity to engage in care, which in turn aects their physical and mental
health outcomes ( Ashaba et al., 2018 , 2019a , 2019b ; Kahana et al.,
2015 ; Mellins and Malee, 2013 ; Tsai et al., 2010a ). These HIV related
challenges are often complicated by structural challenges of poverty,
food and water insecurity, and violence, which are common in many
regions of sub-Saharan Africa, including Uganda ( Dewing et al., 2013 ;
Kang et al., 2011 ; Lund et al., 2010 ; Mushavi et al., 2020 ; Tsai et al.,
2012 , 2016c , 2010b ). Violence against children is also common in this
https://doi.org/10.1016/j.jadr.2021.100094
Received 24 September 2020; Received in revised form 21 December 2020; Accepted 21 January 2021
Available online 23 January 2021
2666-9153/© 2021 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
( http://creativecommons.org/licenses/by-nc-nd/4.0/ )
S. Ashaba, C.E. Cooper-Vince, S. Maling et al. Journal of Affective Disorders Reports 4 (2021) 100094
setting ( Hillis et al., 2016 ). Estimates from the World Health Organiza-
tion show that over 40 million children aged 15 years and below experi-
ence various forms of violence each year, and that the aected children
suer various forms of trauma depending on the severity of the violence
( World Health Organization, 2001 ). Children in sub-Saharan Africa are
frequently exposed to adversities including family violence, orphan-
hood, child labor, and physical punishment, all of which can aect their
mental health ( Brown et al., 2009 ; Hillis et al., 2016 ; Kumar et al., 2017 ;
Lansford et al., 2014 ; Naker, 2005 ; Norman et al., 2012 ).
The risk of exposure to violence increases in adolescence due
to increased and increasingly independent interaction with peers
( Ward et al., 2018 ), particularly in environments characterized by
widespread poverty ( Foster and Brooks-Gunn, 2009 ). The prevalence
of adverse childhood experiences is reportedly higher among adults and
children living with HIV compared with people in the general popula-
tion primarily in sub-Saharan Africa ( Abubakar et al., 2017 ; Bekele et al.,
2018 ; Brezing et al., 2015 ; Cluver et al., 2012 ; Lowenthal et al., 2014 ;
Nyamukapa et al., 2010 ; Yakubovich et al., 2016 ). The increased risk
of adversities among children from HIV-aected families is generally
attributed to stress among parents/caregivers with HIV and associated
lack of adequate supervision ( Cluver et al., 2013 ). In addition, HIV is as-
sociated with other factors that increase the risk of child abuse including
intimate partner violence, substance abuse, depression, and HIV stigma
( Boyes and Cluver, 2013 ; Jewkes et al., 2010b ; Nakimuli-Mpungu et al.,
2011 ). Moreover, children orphaned by HIV who live in child-headed
households or who live with relatives are often maltreated and exploited
( Morantz et al., 2013 ). Common forms of abuse among ALHIV include
both physical and emotional abuse, with the majority of aected ALHIV
reporting experiencing multiple forms of abuse ( Kidman et al., 2018 ;
Radclie et al., 2007 ).
Childhood trauma has been associated with multiple mental health
problems ( Kidman et al., 2018 ). Studies among ALHIV with a history
of child abuse have shown high rates of depression, suicidality, anxi-
ety, low self-esteem, and post-traumatic stress disorder ( Jewkes et al.,
2010a ; Lewis et al., 2015 ; Martinez et al., 2009 ). ALHIV also experi-
ence HIV stigma, discrimination, and lack of support, all of which are
also associated with abuse ( Ashaba et al., 2018 ; Onuoha et al., 2009 ),
leading to further worsening of mental health outcomes ( Ashaba et al.,
2018 , 2019a , 2019b ; Cluver et al., 2010 ; Meinck et al., 2015 ). Al-
though population-based studies are lacking, the prevalence of depres-
sion among ALHIV generally exceeds that among HIV-unaected con-
trols by a factor of two to three ( Bankole et al., 2017 ; Ng et al.,
2015 ). Depression in particular has been associated with reduced treat-
ment adherence, poorer HIV-related outcomes, and increased mortality
( Burack et al., 1993 ; Kacanek et al., 2010 ; Lyketsos et al., 1993 ). Con-
versely, treatment of depression in combination with adherence counsel-
ing has been linked to reduced depression symptom severity, improved
treatment adherence, and increased viral suppression ( Pence et al.,
2015 ; Safren et al., 2016 ; Tsai et al., 2013a , 2010b )
Among ALHIV, social support has been reported to be protec-
tive against the eects of trauma, including depression and suicidal
ideation ( Casale et al., 2019 , 2015a , 2015b ; Newman et al., 2007 ;
Peirce et al., 2000 ). The protective nature of social support against
adverse mental health problems is attributed to the fact that social
support acts as a buer against stressful events ( Cheng et al., 2014 ;
Hussong, 2000 ; Newman et al., 2007 ) and enables people to cope posi-
tively with stressful situations or life circumstances ( Humphreys et al.,
1999 ; Thoits, 2011 ). The relationship between childhood trauma and
depression among ALHIV has not been explored in rural Uganda, and
few studies have explored the potential for modiable moderating inu-
ences in sub-Saharan Africa ( Casale et al., 2015b ). To address this gap
in the literature, this analysis aimed to estimate the association between
childhood trauma, major depressive disorder, and suicidality and to in-
vestigate the potential modifying role of social support among ALHIV in
rural Uganda.
2. Methods
2.1. Study setting and participants
Study participants were enrolled from the HIV clinic attached to
the Mbarara Regional Referral Hospital and Mbarara University of Sci-
ence and Technology within Mbarara Town. The town is approximately
270 km from Kampala, the capital of Uganda, and has a population
of 195,013 ( Uganda Bureau of Statistics, 2014 ). Most of the adoles-
cents attending the adolescent HIV clinic live in rural areas outside
of Mbarara Town, where many families earn a living through sub-
sistence agriculture, animal husbandry, and local trading, and where
challenges of food and water insecurity are common ( Mushavi et al.,
2020 ; Tsai et al., 2011 , 2016a ). The prevalence of HIV in southwest-
ern Uganda is slightly elevated at 7.7% compared with the national
prevalence of 6.2% ( Ministry of Health of Uganda, 2019 ). Among ado-
lescents and young adults, the prevalence of HIV is estimated at 1.1%
among those aged 15–19 years and 3.3% among those aged 20–24
years ( Uganda AIDS Commission, 2018 ). The adolescent HIV care clinic
within Mbarara Hospital is closely linked to the pediatric HIV care clinic
caring for the 0 –9 year olds and the young people’s HIV care clinic car-
ing for the 20 – 25-year-olds. The clinic provides care following the Na-
tional HIV Prevention and Care and Treatment guidelines ( Ministry of
Health of Uganda, 2020 ), which were adopted from the WHO guide-
lines/recommendations for management of adolescents living with HIV.
Our total sample included 224 ALHIV aged 13–17 years who we enrolled
consecutively. We excluded adolescents who could not complete the in-
terview due to physical ailments and those whose HIV status had not
been fully disclosed to them despite being on ART. After screening by
a certied Ugandan psychiatrist, adolescents who exhibited cognitive
impairments that would impact their ability to comprehend the consent
form and contents of the questionnaire were also excluded.
3. Sample size
The study was powered on the basis of estimating the proportion
of ALHIV with comorbid major depressive disorder. Using the 17.8%
prevalence rate estimated in a previous study of children and ALHIV in
Kenya ( Kamau et al., 2012 ), and assuming a two-sided condence in-
terval width of 10%, we estimated a required sample size of 244 ALHIV
( Fleiss et al., 2013 ; Newcombe, 1998 ).
3.1. Study measures
All measures were combined into a single questionnaire that was
translated into the local language (Runyankore). The questionnaire
included questions on self-reported sociodemographic characteristics
including age, sex, level of schooling, duration on ART, caregiver/family
structure (living with both parents, one parent, grandparents, or sib-
lings), whether the participant was bereaved by the loss of one or
both parents, and whether the participant attended a day or boarding
school. Additionally, the questionnaire included the Mini International
Neuropsychiatric Interview for Children and Adolescents (MINI-KID,
version 6) ( Sheehan et al., 1998a ), the Childhood Trauma Questionnaire
(CTQ) ( Bernstein and Fink, 1998b ), the Social Support Questionnaire-
Short Form (SSQ6) ( Sarason et al., 1987 ), the Internalized AIDS-Related
Stigma Scale (IARSS) ( Kalichman et al., 2009 ), and the Social and
Health Assessment Peer Victimization Scale ( Ruchkin et al., 2004 ).
The MINI-KID is a short, structured diagnostic interview that is
used to obtain valid diagnoses of mental disorders in children and
adolescents that are consistent with the Diagnostic and Statistical
Manual of Mental Disorders, 4th edition (DSM-IV) and the International
Statistical Classication of Diseases and Related Health Problems
(ICD-10) ( Sheehan et al., 1998b , 2010 ). The MINI-KID module on de-
pression consists of two screening questions, seven additional questions
2
S. Ashaba, C.E. Cooper-Vince, S. Maling et al. Journal of Affective Disorders Reports 4 (2021) 100094
related to depression symptoms, and one question related to functional
impairment, all with a recall window of the past month. Similarly, the
suicidality module elicits information about suicidal ideation, planning,
and attempts over the past month. We applied the recommended
algorithm to the MINI-KID suicidality scores and categorized study par-
ticipants as being at low, moderate, or high risk for suicide. Those who
scored 17 and above were classied as high risk suicidality. The MINI-
KID has been adapted for use in the Ugandan context ( Idro et al., 2016 ;
Kinyanda et al., 2013 ; Nalugya-Sserunjogi et al., 2016 ; Okello et al.,
2007 ). The MINI-KID modules (major depressive disorder and suicidal-
ity) were administered by a psychiatric clinical ocer with diploma
level training in diagnosing and managing psychiatric disorders.
The CTQ is a self-report screening tool that measures abuse and ne-
glect. It is comprised of 28 items and 6 subscales. Five of these subscales,
each containing 5 items, measure 5 types of maltreatment: emotional,
physical, and sexual abuse; and emotional and physical neglect. Items
10, 16, and 22 comprise the denial subscale. Each item is measured on
a ve-point Likert scale ranging from “Never true ”to “Very often true ”
( Bernstein et al., 2003 ). A score of one or greater on the denial sub-
scale suggests underreporting ( Bernstein and Fink, 1998b ). CTQ items
are elicited in the context of “when I was growing up ”and do not dis-
tinguish between past and current experiences of abuse. Sample items
include: “When I was growing up I got hit so hard by someone in my
family that I had to see a doctor or go to the hospital ”; and, “When I was
growing up, people in my family said hurtful or insulting things to me. ”
The cuto scores used in this study for presence (vs. absence) of abuse
were identical to those established during the scale development stud-
ies ( Bernstein and Fink, 1998a , 1998b ). The cuto scores are: sexual
abuse, ≥ 6; physical abuse, ≥ 8; emotional abuse, ≥ 9; physical neglect,
≥ 8; and emotional neglect, ≥ 10. For the purposes of this analysis, we
dichotomized the subscale scores at the indicated cutos so that par-
ticipants who scored above the cuto were classied as having experi-
enced abuse or neglect while those who scored below the cuto were
classied as having not experienced abuse or neglect. The CTQ scale has
been used in South Africa with good reliability (Cronbach’s alpha = 0.74)
( Meinck et al., 2016 ) and has been validated for use among adults and
adolescents in other regions of sub-Saharan Africa ( Charak et al., 2017 ;
Kounou et al., 2013 ). In our sample, the CTQ had a Cronbach’s alpha of
0.86.
We measured social support using the SSQ6 ( Sarason et al., 1987 ),
a 6-item questionnaire in which participants are asked to list all the
people that they can rely on for support when in need. Each item is a
question that solicits a two-part answer where part 1 asks participants
to list all the people that t the description of the question, and part
2 asks participants to indicate how satised they are with the people
listed. Some of the questions in the SSQ6 include “Whom can you really
count on to be dependable when you need help? ”“Whom can you really
count on to care about you, regardless of what is happening to you? ”
The SSQ6 has high internal reliability and correlates highly with the
original SSQ ( Sarason et al., 1987 ). The SSQ6 Number Score is obtained
by adding the total number of people identied in each of the items, with
a maximum of 9 people per item (score range 0–54). The SSQ6 has been
used among people with HIV with good reliability (Cronbach’s alpha
range between 0.67 and 0.89) ( Hart and Heimberg, 2005 ; Prado et al.,
2004 ; Robbins et al., 2003 ; Wallace et al., 2019 ). It has also been used in
southwestern Uganda among women of reproductive age ( Lubinga et al.,
2013 ).
We measured HIV stigma using the IARSS. The IARSS scale is a
six-item scale that was developed for use among a sample of people
living with HIV from the United States, South Africa and Swaziland
( Kalichman et al., 2009 ). It is one of the most widely used HIV stigma
scales ( Pantelic et al., 2015 ), and it has been validated for use in the
Ugandan context ( Tsai et al., 2013b ). The 6 items in the IARSS focus
on self-blame and concealment of HIV status, and each item has two
response options (agree/disagree). The total scale score is computed as
the sum of the items. Higher scores indicate greater internalized stigma.
We dened high internalized stigma as having a total score greater than
or equal to the 75th percentile ( ≥ 4).
We measured bullying victimization using the nine-item Social and
Health Assessment Peer Victimization Scale, which elicits experiences
of bullying in the past year ( Ruchkin et al., 2004 ). The items are scored
on a four-point Likert-type scale (Never, Once, 2–3 times, ≥ 4 times).
Bullying is dened as having 2 or more bullying events in the past year.
The scale was adapted from the Multidimensional Peer Victimization
Scale in a study conducted among adolescents in the United Kingdom
( Mynard and Joseph, 2000 ) which showed excellent reliability (Cron-
bach’s alpha = 0.82). Subsequent studies conducted among black South
African children and adolescents also showed good reliability (Cron-
bach’s alpha = 0.81) ( Boyes and Cluver, 2015 ; Cluver et al., 2010 ). In
this study, the scale also showed good reliability with a Cronbach’s al-
pha of 0.81.
3.2. Ethical considerations
Participants provided consent prior to enrolling in the study. Ado-
lescents below the age of consent provided assent, after their par-
ent/guardian provided written informed consent. Emancipated minors
(i.e., those below 18 years but living independently), and “empowered ”
adolescents (i.e., those who were responsible for their HIV care per re-
port of their HIV care provider) ( Uganda National Council for Science
and Technology, 2007 ), provided written informed consent without in-
volvement of their parent/guardian. Participants were given consent
forms to read under the guidance of the research assistants and asked
clarication questions where information was not clear. The study was
approved by the Research Ethics Committee of the Mbarara University of
Science and Technology (# 11/04–14) and the Massachusetts General
Hospital/Partners Human Research Committee (2016P000482/MGH).
The study was also cleared by Uganda National Council for Science and
Technology (SS4023) and by the Research Secretariat in the Oce of
the President in line with Ugandan national guidelines for research. Par-
ticipants were given 10,000 Ugandan shillings ( ≈3 USD at the time of
data collection) for transport reimbursement. Participants who devel-
oped acute distress during the interview and/or those who were at a
high risk of suicide, as determined by the assessing psychiatric clinical
ocer, were referred to the psychiatric ward in the hospital to receive
appropriate care.
3.3. Data analysis
We used modied multivariable Poisson regression ( Zou, 2004 ) to
estimate the association between the mental health outcome variables,
childhood trauma, and social support, after adjusting for other po-
tentially confounding variables: sociodemographic characteristics (age,
sex, being an orphan, boarding school or day school, serostatus of
the caregiver), bullying, and internalized HIV stigma. As described by
Zou (2004) , the exponentiated regression coecients can be straight-
forwardly interpreted as relative risk ratios. In these regression models,
we rst included physical, sexual, and emotional abuse separately (ad-
justing for the covariates described above) and then included physical,
sexual, and emotional abuse together in a single regression model (ad-
justing for the covariates described above). The overwhelming majority
of our study participants reported both physical and emotional neglect;
these variables were dropped from the regression models due to multi-
collinearity. We tted separate regression models for major depressive
disorder and any suicidality, or 8 regression models total.
To determine the robustness of the estimated associations,
we performed an E-value analysis using methods proposed by
VanderWeele and Ding (2017) . The E-value describes the minimum
strength of association on the risk ratio scale (between a putative con-
founder and the exposure, and between the putative confounder and
the outcome) that would be needed to explain away the observed asso-
ciation between the exposure and the outcome. A large E-value would
3
S. Ashaba, C.E. Cooper-Vince, S. Maling et al. Journal of Affective Disorders Reports 4 (2021) 100094
Table 1
Characteristics of the sample ( N = 224).
Mean /% SD Freq.
Age (years) 14.87 1.42
Duration on ART (years) 8.43 4.37
Sex
Female 58 131
Male 42 93
Type of school
Day 67 150
Boarding 33 74
Orphan
Yes 22 49
No 78 175
Education level
Some primary 17 38
Completed primary 52 117
More than primary 31 69
Caregiver
Both Parents 27 60
Mother 35 79
Fathe r 10 22
Other (sibling, relative) 13 28
Grandparent 16 35
Caregiver HIV status
Negative 13 28
Positive 65 145
Unknown 23 51
Bullying (2 or more bullying events/year)
Yes 43 97
No 57 127
High level internalized HIV stigma (score ≥ 4)
Yes 41 91
No 59 133
Major Depressive
D isorder
Yes 17 37
No 83 187
Suicidality (any) 14 31
Low risk suicidality 4 9
Moderate risk suicidality 6 13
High risk suicidality 4 9
Childhood trauma
Physical abuse 16 36
Emotional abuse 22 49
Sexual abuse 14 32
Emotional neglect 216 96
Physical neglect 215 96
Social support
High level social support (SSQ6 Number Score > median) 42 94
Low level social support (SSQ6 Number Score ≤ median) 58 130
suggest that potential confounding would need to be very strong in or-
der to serve as a sucient explanation for the observed associations
( Blum et al., 2020 ).
We also sought to determine whether social support modied the as-
sociation between childhood trauma and the mental health outcomes.
This investigation was motivated by previously published conceptual
and empirical work from sub-Saharan Africa showing that social support
modies the association between mental health and adversities (food
insecurity) among adults ( Tsai et al., 2012 , 2016b ). For these analyses,
we created a single trauma exposure variable representing any exposure
to physical abuse, emotional abuse, or sexual abuse. We dichotomized
the SSQ6 Number Score at the median. Eect modication was assessed
by including a main eect for high social support (SSQ6 Number Score
greater than median), a main eect for exposure to any abuse, and a
product term to test for the interaction between any abuse and high so-
cial support. These multivariable regression models also adjusted for the
covariates listed above. We tted separate regression models for major
depressive disorder and any suicidality, or 2 regression models total.
Stratied estimates (high vs. low social support) were also examined to
aid in exposition of the product terms. All analyses were conducted in
Stata version 13 (StataCorp LP, College Station, Texas).
4. Results
We interviewed 224 ALHIV, the majority of whom (131[59%]) were
girls. The mean age was 14.8 years (standard deviation [SD] 1.4). Thirty-
seven participants (17%) had major depressive disorder and 31 (14%)
had suicidality (low, moderate and high risk), of whom 9 (4%) were
classied as having a high-risk suicidality on the MINI-KID. Forty-nine
participants (22%) reported emotional abuse, 36 (16%) reported phys-
ical abuse, 32 (14%) reported sexual abuse , 216 (96%) reported emo-
tional neglect, and 215 (96%) reported physical neglect ( Table 1 ).
We estimated statistically signicant associations between major de-
pressive disorder and both emotional abuse (adjusted relative risk [ARR]
2.57; 95% CI 1.31–5.04; P = 0.006) and physical abuse (ARR 2.16; 95%
CI 1.19–3.89; P = 0.01) ( Table 2 ). When the dierent types of abuse
were mutually adjusted for each other, emotional abuse was the most
important correlate of major depressive disorder (ARR 2.08; 95% CI
4
S. Ashaba, C.E. Cooper-Vince, S. Maling et al. Journal of Affective Disorders Reports 4 (2021) 100094
Table 2
Associations between childhood trauma and major depressive disorder, by type of abuse.
Separately, adjusted for covariates
∗ Mutually adjusted for each other
†
Adjusted risk ratio (95% CI) P-value Adjusted risk ratio (95% CI) P-value
Childhood trauma, by type
Physical abuse 2.16 (1.19–3.89) 0.01 1.37 (0.71–2.67) 0.34
Sexual abuse 1.58 (0.90–2.79) 0.17 1.17 (0.62–2.22) 0.63
Emotional abuse 2.57 (1.31–5.04) 0.006 2.08 (0.99–4.39) 0.05
∗ Each cell represents the output of a single multivariable Poisson regression model tted to the data,
specifying major depressive disorder as the dependent variable and the row header as the primary explanatory
variable of interest, adjusting for age, orphanhood, type of school (boarding versus day), bullying, HIV stigma,
and social support.
† The column represents the output of a single multivariable Poisson regression model tted to the data,
specifying major depressive disorder as the dependent variable and the three types of childhood trauma as
explanatory variables, mutually adjusted for each other and for the other covariates listed above.
Table 3
Associations between childhood trauma and suicidality, by type of abuse.
Separately, adjusted for covariates
∗ Mutually adjusted for each other
†
Adjusted risk ratio (95% CI) P-value Adjusted risk ratio (95% CI) P-value
Childhood trauma, by type
Physical abuse 3.17 (1.60–6.25) 0.001 3.13 (1.45–6.76) 0.004
Sexual abuse 1.00 (0.40–2.46) 0.99 0.62 (0.24–1.58) 0.32
Emotional abuse 2.03 (1.05–3.92) 0.03 1.27 (0.57–2.72) 0.52
∗ Each cell represents the output of a single multivariable Poisson regression model tted to the data,
specifying any suicidality as the dependent variable and the row header as the primary explanatory variable
of interest, adjusting for age, orphanhood, type of school (boarding versus day), bullying, HIV stigma, and
social support.
† The column represents the output of a single multivariable Poisson regression model tted to the data,
specifying any suicidality as the dependent variable and the three types of childhood trauma as explanatory
variables, mutually adjusted for each other and for the other covariates listed above.
0.99–4.39; P = 0.052) although the association was not statistically sig-
nicant. There was also a statistically signicant association between
suicidality and physical abuse (ARR 3.17; 95% CI 1.60–6.25; P = 0.001)
and emotional abuse (ARR 2.03;95% CI 1.05–3.92; P = 0.03) ( Table 3 ).
When the dierent types of abuse were mutually adjusted for each other,
physical abuse was the most important correlate of any suicidality (ARR
3.13; 95% CI 1.45–6.76; P = 0.004) ( Table 3 ).
The E-value analyses suggested that the estimated associations were
robust to potential confounding by unmeasured variables. For the esti-
mated association between emotional abuse and major depressive dis-
order (RR 2.57), the E-value was 4.58. For the estimated association
between physical abuse and suicidality, the E-value was 5.79. Thus, an
unmeasured confounder would need to have a strength of association,
on the risk ratio scale, with both abuse and mental health, between 5
and 6 in order to explain away the reported estimates.
When a main eect for social support was included in the regres-
sion model for major depressive disorder, along with product terms to
test for an interaction between social support and any abuse, social sup-
port moderated the eect of any abuse on major depressive disorder,
but the coecient on the product term was not statistically signicant
( P = 0.076 for interaction). Among study participants with a low level
of social support, the estimated association between any abuse and ma-
jor depressive disorder was statistically signicant (ARR 4.30; 95% CI
1.64–11.25; P = 0.003). Among study participants with a high level of
social support, the estimated association between any abuse and major
depressive disorder was not statistically signicant (ARR 1.30; 95% CI
0.57–2.98; P = 0.52). The estimated association between any abuse and
suicidality did not appear to be modied by social support ( P = 0.87 for
interaction).
5. Discussion
In this clinic-based study of 224 ALHIV in rural Uganda, we show
that major depressive disorder and suicidality were associated with dif-
ferent aspects of childhood trauma. The estimated associations were sta-
tistically signicant, large in magnitude and clinically signicant, and
robust to potential confounding. These ndings add to existing liter-
ature showing an association between childhood trauma and various
mental health problems among youth living with HIV in sub-Saharan
Africa ( Gardner et al., 2019 ; Jewkes et al., 2010a ; Kidman et al., 2018 ;
Woollett et al., 2017 ).
The association between emotional abuse and major depressive dis-
order estimated in our study is similar to what has been documented
in studies in Nigeria and the U.S. ( Adeyemo et al., 2020 ; Murphy et al.,
2000 ). Emotional abuse often leads to low self-esteem, feelings of worth-
lessness, and inability to cope with stress, which may cause depressive
disorder ( Murphy et al., 2000 ). We also estimated a statistically signif-
icant association between suicidality and physical abuse, which echoes
ndings of a previously conducted study in South Africa ( Jewkes et al.,
2010a ). The high suicide risk associated with physical abuse among AL-
HIV may similarly result from feelings of worthlessness and hopelessness
that are further compounded by HIV stigma and discrimination experi-
ences ( Kelly et al., 1998 ).
Our ndings highlight a need to develop interventions aimed at pro-
tecting children and adolescents aected and infected with HIV against
trauma so that associated poor mental health outcomes can be prevented
( Cluver et al., 2018 ; Jewkes et al., 2010a ; Nakimuli-Mpungu et al.,
2014 ). The need to address childhood trauma is paramount since exist-
ing literature shows that exposure to violence is a major risk for mental
health problems among children and adolescents in sub-Saharan Africa
( Skeen et al., 2016 ; Woollett et al., 2017 ) and that adolescents are at
greater risk of exposure to violence than adults and young children
( Devries, 2016 ; Kang et al., 2011 ; Norman et al., 2012 ). Moreover, AL-
HIV are at greater risk of violence and trauma compared with adoles-
cents in the general population ( Abubakar et al., 2017 ; Brezing et al.,
2015 ; Lowenthal et al., 2014 ; Yakubovich et al., 2016 ) due to lack of su-
pervision by parents/caregivers who may be struggling to manage their
own HIV-related stressors ( Cluver et al., 2013 ). Furthermore, HIV is of-
5
S. Ashaba, C.E. Cooper-Vince, S. Maling et al. Journal of Affective Disorders Reports 4 (2021) 100094
ten syndemic ( Tsai et al., 2017 ) with other factors that increase the
risk of childhood trauma, including intimate partner violence, depres-
sion and HIV stigma ( Boyes and Cluver, 2013 ; Jewkes et al., 2010a ).
Many ALHIV come from HIV-aected families, where their living envi-
ronments are characterized by social discrimination and lack of support
with heightened risk of abuse ( Cluver et al., 2011 ; Onuoha et al., 2009 ),
while many others are orphans, further increasing their risk of exposure
to violence through bullying by peers ( Cluver et al., 2010 , 2012 ).
Other ndings from our study indicated that social support had a po-
tentially moderating eect on the eect of any abuse (emotional, phys-
ical, or sexual) on major depressive disorder. While any abuse had a
strong association with major depressive disorder among ALHIV who
had low levels of social support, the estimated association was not sta-
tistically signicant among ALHIV who had high levels of social support.
However, the estimated coecient on the product term was not statis-
tically signicant. This potentially moderating eect of social support
is in line with previous research indicating the role of social support
on mental health outcomes among adolescents in the context of HIV
( Petersen et al., 2010 ; Skeen et al., 2016 ). Social support has been doc-
umented to be protective against adverse mental health outcomes, with
reports indicating that perceived support from peers and caring adults
has positive eects on the mental wellbeing of adolescents despite ex-
posure to stressful life events ( Casale et al., 2015b ; Cheng et al., 2014 ).
Social support has also been documented to be protective against de-
pression among adolescents and adults living with HIV( Ashaba et al.,
2018 ; Matsumoto et al., 2017 ; Nanni et al., 2015 ). This is further rein-
forced by reports indicating that peer support groups within HIV clinics
in Zimbabwe were associated with improved mental health outcomes
among ALHIV ( Mupambireyi et al., 2014 ).
5.1. Limitations
Our ndings should be interpreted bearing in mind certain limita-
tions. First the study was conducted among ALHIV attending a single
HIV clinic in southwestern Uganda, which may limit generalizability of
our ndings only to ALHIV elsewhere in Uganda and sub-Saharan Africa.
Second, our sample consisted of adolescents in a limited age range (13–
17 years), which would have limited our ability to assess trauma ex-
periences among older adolescents in this setting. Third, corporal pun-
ishment is used widely in schools and homes as a form of discipline in
Uganda ( Boydell et al., 2017 ; Devries et al., 2015 ; Kaltenbach et al.,
2018 ). This cultural practice could have biased reporting about physi-
cal abuse, but the direction of bias is unpredictable: some participants
could have perceived corporal punishment as an acceptable practice,
which would have caused us to estimate lower rates of physical abuse;
but other participants who do not believe it to be acceptable may have
had corporal punishment in mind when reporting physical abuse, which
would have caused us to estimate higher rates of physical abuse. Fourth,
the study was cross sectional in nature. We could not estimate the causal
eect of childhood abuse on mental health.
A nal limitation is that confounding by unmeasured covariates
could have biased our estimates. An example of a potentially impor-
tant unmeasured variable is parental incarceration, which could be as-
sociated with both childhood trauma and child mental health. Such con-
founding could induce a spurious correlation between childhood trauma
and child mental health. However, our E-value analysis indicates that
only strong confounding by parental incarceration could explain away
our ndings. Using data from the U.S. Fragile Families and Child Wellbe-
ing Study, Turney (2014) showed that, among children of parents who
lived together prior to connement, paternal incarceration was associ-
ated with increased maternal use of harsh parenting and physical ag-
gression, but the estimated eect size was small in magnitude. There is
also robust evidence to suggest that parental incarceration is associated
with poor mental health among children, with odds ratios ranging from
1.2–1.6 in numerous community samples ( Lee et al., 2013 ; Murray et al.,
2012 ). Thus, estimates from this literature suggest that parental incar-
ceration is unlikely to be a strong enough confounder to explain away
the observed associations. Other potential confounders might exist, but
given the E-values estimated in our study, such a confounder would
need to exceed typical legal standards of causation ( Carruth and Gold-
stein, 2001 ; Mengersen et al., 2007 ) as well as commonly accepted
thresholds exceeding “weak associations ”( Doll, 1985 ; Wynder, 1987 ).
6. Conclusions
Our ndings show that traumatic experiences –in the form of
emotional, physical and sexual abuse –are common among ALHIV
in rural Uganda, and that emotional and physical abuse were associ-
ated with major depressive disorder and suicidality. The ndings also
show that social support potentially moderates the eect of trauma
on major depressive disorder among ALHIV. These ndings highlight
a major public health problem in relation to HIV care among ALHIV
since both childhood trauma and depression have been associated with
sub-optimal adherence to HIV medication, with concomitant worsened
health outcomes ( Fawzi et al., 2016 ; Kim et al., 2017 ; Tsai et al., 2010b ;
Willis et al., 2018 ) and involvement in HIV transmission risk behavior
( Adejumo et al., 2015 ; Cluver et al., 2018 ; Kidman et al., 2018 ). There
is a need to incorporate screening for childhood trauma in clinics for
ALHIV and to develop social support interventions aimed at address-
ing trauma-related challenges and prevention of trauma among ALHIV.
Such interventions will contribute toward improved mental health and
adherence to ART and overall improved health among ALHIV in Uganda.
Declaration of Competing Interest
The authors have no conict of interest to declare.
Funding sources
The study was supported by the U.S. National Institutes of Health
(Fogarty International Center (FIC), National Institute of Mental Health
(NIMH), and National Institute of Neurological Disorders, and Stroke
(NINDS)) under award D43TW010128 . Dr. Tsai acknowledges salary
support through R01MH113494-01, and Dr. Cooper-Vince also acknowl-
edges salary support through T32MH093310.
Author contributions
SA conceived the idea, supervised data collection, analyzed data and
wrote the rst draft of the manuscript. ACT supervised data collection,
guided data analysis and interpretation, and read and edited all drafts
of the manuscript. CEC, SM, ENS, CB, DA, DN, and FB contributed to
reviewing and editing the manuscript. All authors read and approved
the nal version of the manuscript.
Acknowledgements
We acknowledge the contributions of our research assistants in col-
lecting data and providing logistical support: Patricia Tushemereirwe,
Patrick Gumisiriza, Allen Kiconco and Elizabeth Namara. We also thank
the adolescents who participated in the study.
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