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Table 1 Summary of 34 articles selected for review

From: Mental health outcomes in HIV and childhood maltreatment: a systematic review

First author [Reference number] N (HIV +/−) Setting and main characteristics of population Type of study Study design Methods (measurement of exposure and outcomes) Summary of outcomes Childhood maltreatment Mental health outcomes High-risk behaviors and revictimization Treatment adherence
(1) Masten (2007) [31] 49 (49/0). USA.49 bisexual HIV-positive men with childhood sexual abuse (CSA) histories. The majority were African-American men. Intervention study. Baseline survey for a coping group intervention trial. Participants were individually screened at baseline using a structured clinical interview assessing: demographics, sexual abuse history, depression, posttraumatic stress and risk to self or others. (1) Full criteria for posttraumatic stress disorder (PTSD). All participants reported some form of sexual abuse history before the age of 18, with 90% reporting unwanted penetrative anal sex. The average participant age at first abuse was 8.9 years. Most reported more than one abusive experience and frequently had a prolonged abuse exposure. A total of 21 men (42.9%) met criteria for PTSD.   
(2) Mimiaga (2009) [8] 4295 (258/4037). USA.4295 men who have sex with men (MSM) enrolled in the EXPLORE study. Intervention study. Longitudinal research design. Intervention lasted 48 months with assessments every 6 months. HIV infection was the primary efficacy outcome. Abuse histories, drug and alcohol use and other psychosocial factors were assessed. A shortened version of the Center for Epidemiologic Studies Depression Scale (CES-D) assessed depression. (1) Depression.
(2) Drug use.
39.7% had a history of CSA. Participants with a history of CSA were at increased risk for HIV infection over study follow-up. Among participants reporting CSA, the EXPLORE intervention had no effect in reducing HIV infection rates. Participants reporting CSA were significantly more likely to have symptoms of depression and use nonprescription drugs.   
(3) Sikkema (2008) [32] 247 (247/0). USA. 130 women and 117 men with a history of CSA. All men reported having sex with men. Intervention study. Randomized controlled behavioral intervention trial with 12-month follow-up. A structured interview assessed depression, PTSD, and risk to self or others. A modified and expanded version of the Traumatic Experiences Questionnaire (TEQ) assessed exposure to traumatic events, including sexual abuse during childhood, and adulthood. (1) Sexual revictimization.
(2) PTSD.
The average age of first abuse was 8.8 years. Most (90%) experienced penetrative vaginal or anal sexual abuse as a child or adolescent; 87% experienced sexual revictimization, with more than half of those revictimized as children or adolescents. Only 10% of participants reported a single episode of abuse. On average, CSA lasted 4 years and participants had 2 abusers (only 39% of participants reported 1 abuser). 40% of the sample met diagnostic criteria for PTSD.   
(4) Sikkema (2004) [33] 28 (28/0). USA. Twenty-eight HIV-positive participants (7 men and 21 women). Intervention study. Baseline survey for a coping intervention trial. Trauma Symptom Checklist: childhood and adult traumatic experiences. Personality Assessment Inventory: self-administered objective inventory of adult personality. Trauma Symptom Inventory (TSI): acute and chronic posttraumatic symptomatology. (1) Mood disorders.(2) Anxiety disorders, including PTSD.(3) Substance abuse.(4) Personality disorder.(5) Revictimization Prior to age 12, 71.4% reported oral sexual abuse and 85.7% reported penetrative anal sexual abuse. During adolescence, 57.1% of the men experienced some form of sexual abuse. 76.2% of women reported unwanted touching or fondling, 25% reported oral sexual abuse, and 57.1% reported penetrative anal or vaginal sexual abuse during childhood (age 12 or younger). During adolescence, 85.7% unwanted touching or fondling, 57.1% oral sexual abuse, and 81.0% penetrative anal or vaginal sexual abuse. 85% of the participants received an indicator of an Axis I diagnosis: the most frequent diagnostic categories were mood disorders (46.4%), anxiety disorders, including PTSD (32%), and substance abuse (25%). On Axis II, 28.5% received at least one diagnostic indicator of a personality disorder.   
(5) Sikkema (2007) [34] 198 (198/0). USA. 107 women and 91 men with CSA. All men reported having sex with men. Intervention study. Baseline survey for a coping intervention trial. Depressive symptomatology: Beck Depression Inventory (BDI). The Impact of Events Scale: PTSD symptoms. (1) PTSD. 89% of participants experienced penetrative anal or vaginal abuse during childhood or adolescence. Fifty-five percent of participants reported sexual abuse during both childhood and adolescence. 40% of study participants met DSM-IV diagnostic criteria for PTSD.   
(6) Williams (2008) [35] 137 (137/0). USA. 137 HIV-positive gay and non-gay identifying African-American and Latino men with histories of CSA. Intervention study. Randomized clinical trial compared the effects of two 6-session interventions. A randomized clinical trial aimed at decreasing high-risk sexual behaviors, number of sexual partners, and depressive symptoms. The CES-D assessed depression. (1) High levels of depression at baseline.(2) Significant decrease in depression from 3 to 6 months follow-up. Histories of CSA. There were high levels of depression at baseline, M = 23. There was a significant decrease in depressive symptoms from the 3 month to the 6 month follow-up assessment for the sample as a whole (M = 22.42, for 3 months depression and M = 20.66 for 6 months depression).   
(7) Holmes (1997) [36] 95 (95/0). USA. 95 HIV seropositive men. The majority were Caucasian men (67%). Sexual practices were homosexual/bisexual in 87 (92%) participants. Survey HIV + only Quantitative cross-sectional survey design. Sociodemographic and sexual abuse histories were obtained. The Structured Clinical Interview for the DSM Disorders) was used to identify Psychoactive Substance Use Disorder (PSUD). (1) PSUD. (2) Increased risk of intravenous drug use (IVDU). Nineteen (20%) participants had sexual abuse histories. First abuse occurred at a mean age of 8.1 years. Fifty-five (58%) participants met the criteria for a diagnosis of PSUD at some time in their lifetime and nine (9%) currently met diagnostic criteria. Men with histories of sexual abuse did not exhibit a significantly increased risk of lifetime or current PSUD. When rates were examined by type of administration method, men with reported histories of sexual abuse did show a significantly increased risk of lifetime IVDU.   
(8) Myers (2006) [37] 147 (147/0). USA. 147 HIV-positive women. The majority were African-American (n = 79). Survey HIV + only Baseline survey for a risk reduction intervention trial. CSA: revised Wyatt Sex History Questionnaire (WSHQ-R). PTSD: PTSD diagnostic module of the University of Michigan version of the Composite International Diagnostic Interview. Trauma-related sexual symptoms were assessed with the TSI. Depression was assessed with the CES-D. (1) More PTSD symptoms in those abused by a family member or by both a family and non-family member. 18% of the women reported one or more less severe sexual abuse incidents. 40% experienced one severe incident, including attempted or completed oral, anal, or vaginal sex, and digital penetration. 18% experienced one severe and one or more less severe incidents, and 24% experienced two or more severe incidents. 34% of the women reported being abused by a perpetrator that was not a family member. 43% reported abuse by a family member, and 24% experienced being abused by both intra- and interfamilial perpetrators. The mean number of sexual abuse incidents was 1.8, with a range of 1 to 6 incidents, and on average, the abuse continued for 2 years. The relationship to perpetrator was a significant predictor of PTSD symptoms, with more PTSD symptoms among those who reported intrafamilial abuse or both intrafamilial and extrafamilial abuse compared with those who reported only experiencing extra familial abuse.   
(9) Roy (2003) [38] 149 (149/0). USA. 149 HIV positive substance-dependent patients. There were more males than females in the sample and the majority were African-American. Survey HIV + only Quantitative cross-sectional survey design. Structured Clinical Interview for DSM-IV: depression. The Eysenck Personality Questionnaire (EPQ) assessed neuroticism, extraversion, and psychoticism. The Childhood Trauma Questionnaire (CTQ) assessed for childhood abuse and neglect. (1) Suicidality(2) Substance dependence.(3) Lifetime depressive disorder.4) High neuroticism scores. HIV positive patients who had attempted suicide had significantly higher scores on the CTQ for childhood emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect. 66 (44.3%) had attempted suicide and 83 (55.7%) had not. Significantly more of those who had attempted suicide were female. Of the 66 patients, 51 who had attempted suicide had a primary substance dependence diagnosis. Significantly more of the patients who had attempted suicide had a lifetime history of a depressive episode. HIV positive attempters also had significantly higher neuroticism scores on the EPQ.   
(10) Allers (1999) [39] 52 (52/0). USA. 52 HIV-positive individuals. Of the 45 male and 7 females, 36 were White and 16 were Black. Survey HIV + only Qualitative survey design. A semi-structured interview conducted by male HIV counselors. This interview tapped into variables such as: history of childhood abuse, pre-HIV histories of abusive or revictimizing relationships or both, depression, sexual compulsivity and alcohol or other drug abuse. (1) History of alcohol or drug abuse.(2) Chronic depressive symptomatology.(3) Revictimization.(4) Sexually compulsive behaviors. A total of 65% (n = 34) reported a history of childhood sexual or physical abuse or both. 35.3% (n = 12) reported physical abuse only, and 64.7% (n = 22) reported sexual abuse. All 22 participants reporting sexual abuse also reported some additional form of childhood physical abuse. Of these participants, 88% (n = 30) reported a history of alcohol or other drug abuse, 82% (n = 28) reported revictimizing relationships, 68% (n = 23) reported chronic depressive symptomatology, and 50% (n = 17) reported engaging in sexually compulsive behaviors. Of these participants, 88% (n = 30) reported a history of alcohol or other drug abuse, and 68% (n = 23) reported chronic depressive symptomatology. 82% (n = 28) reported revictimizing relationships, and 50% (n = 17) reported engaging in sexually compulsive behaviors.  
(11) Brennan (2007) [40] 936 (936/0). USA. 936 gay and bisexual men. The majority (95.3%) were gay and White (88.8%) men. Survey HIV + only Quantitative cross-sectional survey design: retrospective data. A self-administered survey investigating: HIV/sexually transmitted infection (STI) status, self-defined current use of sex-related drugs, other HIV risk behaviors and history of CSA. (1) Current drug abuse.(2) Transactional sex practices. 15.5% (n = 134) of survey respondents reported a history of CSA. Those who reported experiencing abuse regularly were more likely to be HIV positive. Those who reported experiencing abuse regularly were more likely to be a current user of sex-related drugs. Those who reported experiencing abuse regularly were more likely to have exchanged sex for payment, and be a current user of sex-related drugs.  
(12) Clum (2009) [41] 40 (40/0). USA. 40 young HIV-positive women recruited from HIV clinics. Survey HIV + only Mixed method design (qualitative and quantitative surveys). A modified version of the Life Story Interview was used to cover abuse experiences, cognitive and emotional consequences of abuse, coping strategies, and sexual behavior and relationships. PTSD symptoms were assessed with an interviewer-administered Posttraumatic Diagnostic Scale. (1) PTSD symptomatology ranging from mild to severe.(2) Reported difficulties in sexual, family, and friend relationships, general life satisfaction, and leisure time activities.(3) Substance abuse. 75% of the women reported sexual abuse, 80% reported physical abuse, and 55% reported both types of abuse. The average PTSD score was 20.75, reflecting moderate to severe levels of PTSD symptoms. 15% of the sample reported mild PTSD symptoms (<10), 37.5% reported moderate symptoms (10 to 20), 30% reported moderate to severe symptoms (21 to 35), and 15% reported severe symptoms (>35). Avoidance and substance use were frequently utilized as coping strategies.   
(13) Cohen (2004) [25] 1165 (1165/0). USA. 1165 HIV-positive women. 635 participants were using highly active antiretroviral therapy (HAART), 254 participants not using HAART although it had been indicated and 276 participants not on HAART which had not been indicated. Survey HIV + only Quantitative survey design. A standardized interview-based survey assessed demographics, medical and psychosocial history, history of cigarette smoking, alcohol use, illicit drug use and drug treatment programs, sexual history and history of medication use, and reasons for non-adherence at each 6-month visit. The CES-D measured depressive symptoms. Women were also asked questions about physical, sexual, or emotional coercion. (1) Poor treatment adherence.(2). Drug abuse.(3) High levels of depression in all groups. 72% of women using HAART reported a history of physical or sexual abuse. For women who were not using HAART, 80% reported a history of physical or sexual abuse. Current crack, cocaine, or heroin use, being non-White, and experiencing any physical or sexual abuse increased the likelihood of no HAART use. A lower percentage of women with a history of past and current use of crack, cocaine, or heroin were using HAART. Women in the groups did not differ significantly in having high levels of depressive symptoms.   A lower percentage of women with a history of physical or sexual abuse reported using HAART. Women who used crack, cocaine, or heroin in the past year were more than twice as likely to report lack of HAART use, even when indicated. Similarly, women with a history of any physical/sexual abuse were more than 1.5 times more likely to lack HAART when clinically eligible.
(14) Gielen (2001) [26] 287 (287/0). USA. 287 HIV-positive women. 94% of the women were African-American. Survey HIV + only Quantitative cross-sectional survey design. Health status and quality of life were evaluated with a modified version of the Medical Outcomes Study HIV Health Survey. HIV-related characteristics, social support and health promoting behaviors were assessed. Adult violence history and whether they had ever been sexually abused or raped as a child was assessed using a dichotomous response variable (yes/no). (1) Drug abuse.(2) Poor mental health, physical functioning, and quality of life.(3) Social networks and health promoting behaviors improved mental health. A history of CSA was reported by 41% of the sample. 55% had a history of injection drug use. Women with a history of child sexual abuse reported significantly lower scores on measures of mental health, physical functioning, and quality of life. Women with larger social networks and who practiced more health promoting behaviors reported higher levels of mental health, whereas those who had been sexually abused as children reported significantly worse mental health. 63% reported having been physically or sexually assaulted at least once as an adult.  
(15) Henny (2007) [42] 644 (644/0). USA. HIV-seropositive homeless or unstably housed adults (n = 644). The sample included 15 male-to-female transgender people Survey HIV + only Quantitative cross-sectional survey design. Dichotomous variables (yes/no) assessed adult and childhood abuse, and current and lifetime illicit drug use. The CAGE questionnaire investigated alcohol use. Depressive symptoms were measured by the CES-D. Self-perception of stress was measured using the Perceived Stress Scale. (1) Alcohol abuse.(2) Depressive symptomatology.(3) Transactional sex. 80.3% of the sample reported a history of any physical or sexual abuse. 53% reported childhood physical abuse and 38.7% reported CSA. Victims of CSA were nearly three times as likely to be female. Victims of childhood physical abuse were more likely to have abused alcohol. Persons experiencing childhood physical abuse also were twice as likely to report symptoms indicating depression. Persons experiencing childhood physical abuse also were twice as likely to have ever exchanged sex for money, drugs, or shelter.  
(16) Kalichman (2002) [28] 357 (357/0). USA. 357 men and women living with HIV/AIDS. Study participants were 242 (68%) men, 110 (31%) women, and 5 (1%) transgender persons. The majority of the sample was African-American (76%). Survey HIV + only Quantitative cross-sectional survey design. A dichotomous variable (yes/no) assessed sexual abuse history and substance abuse history. Trauma indicators were adapted from diagnostic symptoms of PTSD. Symptoms of depression were assessed with the CES-D. The Trait-Anxiety Scale assessed anxiety. A 6-item scale to assess pessimism was developed. Symptoms of obsessiveness–compulsiveness were assessed using six items from the Obsessive–Compulsive Scale of the schedule for nonadaptive personality (SNAP). Similarly, six items from the Borderline Personality Scale of the SNAP were used to assess borderline personality characteristics. (1) Substance abuse.(2) Anxiety symptoms.(3) Depression symptoms.(4) Borderline personality symptoms.(5) Current PTSD symptoms.(6) Trauma symptoms correlated with the number of sexual assaults reported. 68% of women and 35% of men living with HIV/AIDS reported a history of sexual assault since age 15. History of sexual assault was related to history of substance use and mental health treatment. Sexual assault survivors reported greater anxiety, depression, and symptoms of borderline personality than persons who had not been sexually assaulted. Persons who reported having been sexually assaulted reported current trauma symptoms. Specifically, 24% stated that they think of the experience on a regular basis, 20% have nightmares about the experience, 60% reported that the experience affects them today, and 47% stated that the experience interferes with their relationships. Number of trauma symptoms correlated with the number of sexual assault experiences reported.   
(17) Kang (2008) [43] 220 (220/0). USA. All participants were HIV-positive heroin and/or crack cocaine using African-Americans or Hispanics. There were 146 males and 74 females. Survey HIV + only Baseline survey for an intervention study. Childhood abuse experience: CTQ. Depression: CES-D. Health status items included: general health rating and HIV-related symptoms. Lifetime medical conditions were also examined. (1) Alcohol and drug abuse.(2) High depression levels.(3) Poor treatment adherence. Women were more likely to report CSA (51% versus 39%) and childhood physical abuse (64% versus 54%). Men were more likely to use alcohol to intoxication and currently inject drugs, and females were more likely to use crack. Both men and women had high depression levels. 81% of women and 76% of men had a score of 16 or higher on the CES-D.   For both men and women, use of HIV medications was negatively associated with CSA experience.
(18) Kimerling (1999a) [44] 67 (67/0). USA. Sample included 67 African-American HIV-infected women beyond the initial stages of HIV infection. Survey HIV + only Longitudinal design: 12–14 months apart, with an average time of 13.4 months apart. Life Stressor Checklist: identify life stressors with greater prevalence for women. Impact of Events Scale-Revised: the presence and intensity of PTSD symptoms. (1) PTSD (both symptom clusters and full criteria). 62% of the sample reported experiencing at least one traumatic event. 30% of the sample experienced completed rape and 33% experienced physical assault. These both included rape and assault as a child. The majority who met the stressor criterion also met criteria for at least one other symptom cluster for PTSD, whereas 35% of the sample met full criteria. 88% of the sample met criteria for the re-experiencing symptom cluster, 74% for the avoidance/numbing symptom cluster and 70% for the hyper arousal symptom cluster.   
(19) Martinez (2002) [45] 41 (41/0). USA. 41 HIV-positive women. The majority of the sample (51%) was African-American. Survey HIV + only Quantitative cross-sectional survey design: retrospective data. The Life Stressor Checklist-Revised was completed in order to examine the frequency and types of traumatic life events. The PTSD Checklist-Civilian Version 29 was used to assess current PTSD symptoms. (1) Partial and full PTSD.(2) Level of PTSD significantly related to number of life events experienced and perceived social support. 61% of women had experienced growing up with violence in the home. 59% were emotionally abused or neglected. 32% had been abused or physically attacked by a known person before the age of 16. Similarly, 32% were sexually touched or made to touch someone before age 16 and 31% were forced to have some type of sex before age 16. 42% of the HIV-positive women were likely to meet criteria for full current PTSD and an additional 22% for partial PTSD. Women reported having experienced a mean of 12 traumatic life events. The level of PTSD was significantly related to the number of life events experienced and to perceived social support from friends and family.   
(20) Martinez (2009) [46] 174 (174/0). USA. HIV-positive youth enrolled in a young adult HIV clinic between 1998 and 2006. 58 were females and 116 were males. The majority (79%) were African-American. Survey HIV + only Quantitative cross-sectional survey design. Client Diagnostic Questionnaire was used to screen for mental health disorders and violence. All youth subsequently had diagnostic interviews conducted by psychologists. (1) Major depressive disorder (MDD).(2) Generalized anxiety disorder.(3) PTSD.(4) Alcohol and substance abuse disorders. Violence reported included physical abuse (24% in childhood; 19% in adolescents), sexual abuse (28% in childhood; 15% in adolescents), dating violence (18%), and family violence (44%). Females had higher sexual abuse (P < .001). Psychological disorders included: MDD (15%), generalized anxiety disorder (17%); PTSD (28%); alcohol abuse disorder (19%); and substance abuse disorder (31%). Physically abused youth had higher symptoms of anxiety and PTSD. Sexually abused youth had higher symptoms of PTSD (P < 0.05). Youth with family violence had higher symptoms of Anxiety Disorder (P < 0.05) and PTSD (P < 0.01).   
(21) McKeown (2003) [47] 20 (20/0). Canada. 20 HIV-positive women. Eighteen (90%) self-identified as aboriginal. Survey HIV + only Qualitative research design. Open ended interviews were conducted to obtain information on childhood and adulthood experiences. (1) Drug abuse as coping strategy.(2) Transactional sex.(3) Past suicide attempts.(4) Reported diagnoses of MDD, PTSD, schizophrenia, panic disorder, and multiple personality disorder. Women who had experienced CSA. A few of the women recounted past attempts of suicide. A number of women, at the time of the interview, reported a diagnosis of mental illness including depression, multiple personality disorder, panic attacks, PTSD and schizophrenia. Most participants reported IVDU on a regular basis in the past, with one reporting current use of IV drugs. The majority who experienced CSA reported involvement in the sex trade and drug abuse as economic and emotional survival/coping strategies.  
(22) Meade (2009) [7] 271 (271/0). USA. 271 HIV-positive individuals with histories of CSA. 50% female and 69% African-American. The men were primarily (94%) gay/bisexual. Survey HIV + only Baseline survey for a coping intervention trial A modified version of the TEQ was used to verify childhood abuse history. The BDI was used to identify severe depression. (1) Depressive disorder.(2) Anxiety disorder.(3) Psychotic disorder.(4) Adjustment disorder.(5) Bipolar disorder.(6) Alcohol and drug abuse.(7) Undergone mental health treatment. 271 HIV-positive individuals with histories of CSA. Approximately half of the sample (53%) screened positive for one or more psychiatric disorders (30% depressive, 25% anxiety, 11% psychotic, 10% adjustment, 4% bipolar). Approximately one third (37%) used illicit drugs and 10% reported binge drinking in the past 4 months. Many participants also received mental health treatment in the past 4 months. Those screening positive for a psychiatric disorder were more likely than those who did not to have received mental health treatment (59% versus 41%).   
(23) Pence (2007) [29] 611 (611/0). USA. 611 HIV-infected individuals. Sixty four percent of participants were African-American and 31% were female. Survey HIV + only Quantitative cross-sectional survey design. Patients completed the Brief Symptoms Inventory (BSI), an assessment of current psychological symptoms. Substance use was measured with the Addiction Severity Index. PTSD symptoms were assessed with the PTSD Checklist. (1) PTSD.(2) More than half had a probable psychiatric disorder on the BSI.(3) High levels of depression.(4) High levels of anxiety.(5) Substance abuse. Most respondents (91%) reported experiencing at least one traumatic event in their lifetime. 30.4% experienced CSA and 20.6% severe physical abuse as a child. 16% of the sample met criteria for PTSD, 53.9% of the sample had a probable psychiatric disorder on the BSI. 34.7% of the sample had depressive symptoms above the 90th percentile and 29.5% had anxiety symptoms above the 90th percentile. 22.3% of the sample was engaging in any non-marijuana substance abuse and 20% were using multiple substances.   
(24) Sikkema (2009) [48] 256 (256/0). USA. 256 HIV-positive adults with CSA histories. There were 132 women and 124 MSM. The majority (67.3%) was African-American. Survey HIV + only Quantitative cross-sectional survey design. A modified version of the TEQ assessed abuse history. Depression and suicidal ideation: BDI. TSI: PTSD. Substance abuse and sexual behavior were also assessed using self-developed screening tools. (1) Sexual revictimization.(2) Mood and anxiety symptoms.(3) PTSD symptoms.(4) Alcohol and drug use. All participants reported abuse histories. 90% had experienced penetrative vaginal or anal sexual abuse as a child or adolescent. The mean score for mood and anxiety symptoms was 29.8 in women and 28.2 in men. Mean score for trauma-related symptoms was 40.4 in women and 28.9 in men. Alcohol use in the past 4 months was 31.8% in women and 53.2% in men. Marijuana use in the past 4 months was 18.2% in women and 36.3% in men. Cocaine and/or Crack use in the past 4 months was 18.9% in women and 33.1% in men. 87% experienced sexual revictimization at some point in their lives.  
(25) Simoni (2000) [49] 230 (230/0). USA. Sample consisted of 230 HIV-positive women. The majority (46%) described themselves as African-American. Survey HIV + only Quantitative cross-sectional survey design. Demographics, trauma, coping strategies and current depressive symptomatology were assessed. Respondents completed the CES-D. Self-reported trauma histories were documented. (1) High scores of depressive symptoms.(2) Positive correlation between childhood abuse and current adaptive and avoidant coping strategies.(3) Avoidant coping was strongly associated with CES-D scores. A high prevalence of abuse in childhood (50%) and adulthood (68%); 7% reported physical assault or rape in the last 90 days. Childhood abuse was significantly correlated with both adult and recent trauma, and each type of trauma correlated with CES-D scores. The mean CES-D score was 22.49; 66% had a sum score of 16 or above, indicative of possible clinical depression.   
(26) Tarakeshwar (2005) [50] 28 (28/0). USA. 28 HIV-positive women with CSA histories. The majority were African-American (67.9%). Survey HIV + only Qualitative research design. A clinical psychologist and a social worker conducted in-depth qualitative interviews. The interview was developed on the basis of the published literature and the goal of developing a coping-focused intervention for women with CSA history and HIV. The interview protocol used a semi-structured interview format that addressed the impact of sexual abuse and HIV on their life and the ways they coped with these traumas. (1) Reported cumulative trauma-related distress.(2) Current use of psychiatric medications for: depression, anxiety (agoraphobia, panic disorder), PTSD.(3) Frequent hospital visits for physical complaints.(4) Substance abuse.(5) Revictimization. 78.6% of the sample revealed unwanted touching or fondling, 57.1% reported sexual intercourse, and 57.1% were asked to engage in sexual acts under verbal and emotional pressure (before 13). During adolescence (13–17 years), their reports of unwanted sexual abuse experiences increased: 82.1% for intercourse, 64.3% for oral sex, 71.4% for forced or threatened sexual acts, 75.0% for verbal and emotional pressure, and 35.7% for unwanted sexual acts that occurred when they had passed out or were drunk or asleep. Many (40%) of the women were abused by family members. Most of the women reported having encountered multiple traumatic experiences and reported cumulative distress as a result of these experiences. Many were using psychiatric medications for symptoms of depression, anxiety (e.g., agoraphobia, panic disorder), and PTSD. PTSD such as flashbacks and hyper vigilance around places and occasions that reminded them of their sexual abuse were common. A few women stated that their distress led to frequent visits to the hospital for physical complaints as they psychologically struggled to comprehend their sexually abusive experiences since childhood. Using illicit substances (e.g. drugs) helped all the women numb their symptoms of emotional distress and feelings of anger and betrayal generated by their CSA. 75% reported sexual revictimization.  
(27) Tarakeshwar (2006) [51] 266 (266/0). USA. 266 HIV-positive participants. There were 133 males, 129 females, and 4 transgender. The majority (71.5%) was African-American. Survey HIV + only Quantitative cross-sectional survey design. Participants were screened for abuse histories in childhood, adolescence, and adulthood. The BDI was used to assess depressive symptomatology. Perspectives on addressing trauma symptoms, HIV-related stress, and resiliency were also assessed using self-developed screening tools and modified scales. (1) Substance use treatment in the past four months.(2) Lower resiliency and greater HIV-related stress was related to negative feelings about addressing trauma.(3) Revictimization. 91% of the participants had been sexually abused as children, 77% had been abused during adolescence. 71.5% of men and 66.7% of women reported unwanted vaginal or anal sex in childhood. 54% of men and 52% of women had at least one visit to a mental health provider in past 4 months. 39.5% of men and 38% of women were on psychiatric medications. Substance use treatment in the past 4 months was reported in 38.8% of men and 29.5% of women. 56% had been sexually revictimized as adults.  
(28) Welles (2009) [30] 593 (593/0). USA. 593 HIV + MSM. Survey HIV + only Baseline survey for a risk reduction intervention trial. Participants reported the frequency of CSA. Brief Symptom Checklist was used to assess depression and anxiety. (1) High levels of depression.(2) High levels of anxiety.(3) Reported current and lifetime alcohol and drug problems. Of participants, 47% reported CSA, with 32% reporting CSA occurring often or sometimes. Although most (154 or 58%) reported the gender of the perpetrator as male, 38 (14%) reported CSA by a female, and 75 (28%) by both. HIV + reporting history of CSA had significantly higher levels of depression and anxiety, with 39% reporting the highest quartile scores for the depression and anxiety inventory, compared with 24% of men reporting no CSA. Men reporting CSA were more likely to believe that they have or had problems with drugs or alcohol.   
(29) Wyatt (2005) [52] 75 (75/0). USA. 75 HIV-positive women with histories of CSA. Survey HIV + only Baseline survey for an intervention trial. Women were administered the WSHQ-R. Five measures were used to assess patterns of substance abuse. (1) Substance abuse.(2) Lifetime alcohol or drug treatment. All women in the sample had a history of CSA. 83% of the sample reported having used at least 1 of 13 substances regularly at some point in their lives. 28% of the sample reported engaging in regular injection drug use. 54% of the women reported having taken part in an alcohol or drug treatment program at some point in their lifetime.   
(30) Paxton (2004) [53] 457 (299/158). USA. 65.4% of the sample was HIV-seropositive. The majority of the sample was African-American. General survey (mixed). Quantitative cross-sectional survey design. Alcohol and drug abuse/dependence, depression, and panic disorder: subscales of the University of Michigan Revised Short Form of the Composite International Diagnostic Inventory. Posttraumatic stress symptoms: revised 17-item short form clinical checklist. Select items from the WSHQ-R measured exposure to sexual and other lifetime trauma. (1) PTSD symptoms.(2) Substance abuse.(3) Risky health behaviors.(4) Chronic stress.(5) History of psychiatric disorders. HIV-positive women were more likely to report a history of CSA. HIV-positive women with a history of CSA were more likely to report posttraumatic stress, substance abuse, chronic stress, and psychiatric history than HIV-negative counterparts. HIV-positive women with a history of CSA were more likely to report risky health behaviors than HIV-negative counterparts.  
(31) Cohen (2000) [6] 1645 (1288/357). USA. 1288 HIV-positive women and 357 HIV-negative women. The majority (64%) were African-American. General survey (mixed). Quantitative cross-sectional survey design: retrospective data. A survey investigating three areas of violence: any domestic violence, recent domestic violence and CSA. Lifetime substance abuse and injection drug use in the past 6 months was assessed. Finally, HIV risk behaviors were assessed. (1) Drug use.(2) HIV-risk behaviors.(3) Revictimization. 31% of HIV-positive women reported a history of CSA Women reporting past domestic violence or CSA were more likely than women without such histories to have used drugs at some point in their lives. Women reporting past domestic violence or CSA were more likely than women without such histories to have had more than 10 lifetime male partners; to have traded sex for money, drugs, or shelter; and to have been forced to have sex with a person known to be HIV positive. Women who reported CSA were more likely to report a lifetime history of domestic violence and to have experienced domestic violence in the past year.  
(32) Kalichman (2004a) [3] 272 (6/19), South Africa. 272 women living with sexual assault histories. Nearly all (99%) of the women were African. General survey (mixed). Quantitative cross-sectional survey design. Self-administered anonymous surveys assessing sexual assault history, substance use, history of HIV risk factors, and sexual behavior. (1) Alcohol and drug use.(2) Transactional sex 6 women (11%) were HIV-positive and 19 (33%) were HIV-negative. The majority of women (56%) did not know their HIV status. 40% (N =/119) of women reported a history of sexual assault. 26 (21%) of the women had experienced sexual assault before the age of 20.   Women who had been sexually assaulted were significantly more likely to have shared injection drug equipment, exchanged sex to meet survival needs, and used alcohol compared to women who had not been sexually assaulted.  
(33) Kalichman (2004b) [54] 647 (498/142). USA. 647 men with CSA histories. The majority were Caucasian (70%). General survey (mixed). Quantitative cross-sectional survey design. Self-administered surveys were used to assess demographics, sexual abuse history, substance use and sexual risk behaviors. (1) Symptoms of borderline personality disorder.(2) Alcohol and drug abuse.(3) Having undergone treatment for substance abuse. 93 (15%) of the men reported being forced to have sex when they were 16 years or younger by a man at least 5 years older. Of these 93 men, the average age of first abuse was 9.3 years. Sexually abused men were more likely to report childhood physical abuse relative to non-abused men (41% vs. 12%). Men who were sexually abuse were more likely to have tested HIV-positive (40%) relative to non-abused men (19%). 77% of the men were HIV-negative and 22% were (9%). HIV-positive. Abused men endorsed more symptoms of borderline personality disorder. Contrary to expectations, abused men did not differ in dissociation symptoms or trauma-related anxiety when compared to non-abused counterparts. Abused men were more likely to report alcohol and drug abuse in the past 6 months and having undergone treatment (28%) compared to non-abused men.   
(34) Kimerling (1999b) [27] 236 (88/148). USA. 88 African-American HIV-infected women and 148 uninfected women. General survey (mixed). Quantitative cross-sectional survey design: retrospective data. The Life Stressor Checklist: history of victimization. The BSI: level of general or global distress. The Hamilton Clinician’s Rating Scale for Depression: depression and to serve as a more objective measure of psychological distress. (1) High levels of global psychological distress.(2) Depression.(3) Greater physical distress and AIDS-defining conditions. A history of completed rape contributed the greatest risk for HIV infection. Women who reported completed rape identified the worst experience to have occurred at 18.27 years old. This variable included rape as a child. HIV-infected victims reported higher levels of global psychological distress, and greater severity of clinician-rated symptoms of depression. HIV-infected victims also reported significantly greater distress with physical symptoms and higher rates of AIDS-defining conditions than did non-victims.   
  1. BDI, Beck Depression Inventory; BSI, Brief Symptom Inventory; CES-D, Center for Epidemiologic Studies Depression Scale; CSA, childhood sexual abuse; CTQ, Childhood Trauma Questionnaire; EPQ, Eysenck Personality Questionnaire; HAART, highly active antiretroviral therapy; IVDU, intravenous drug use; MDD, Major depressive disorder; MSM, men who have sex with men; PTSD, posttraumatic stress disorder; PSUD, Psychoactive Substance Use Disorder; SNAP, schedule for nonadaptive personality; STI, sexually transmitted infection; TEQ, Traumatic Experiences Questionnaire; TSI, Trauma Symptom Inventory; WSHQ-R, revised Wyatt Sex History Questionnaire.