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Detecting post-traumatic stress disorder (PTSD) among antiretroviral therapy (ART) users is an important matter in the context of providing public health services. In South Africa, the country with the largest number of persons living with HIV, the prevalence of community violence and its psychological consequences, including PTSD are high. Among both persons seeking an HIV test and persons living with HIV (PLWH), traumatic events and symptoms of posttraumatic stress have been reported in non-trivial proportions. Stressful life events and consequent traumatic stress have shown a strong association with sub-optimal ART adherence, which in turn predicts virologic failure. Also, among ART user who have PTSD, immune functioning may be impaired, somatization and physical disorders may occur at elevated levels, and symptoms such as persistent avoidance and re-experiencing the traumatic event may reduce quality of life.
Screening for common mental health disorders such as PTSD is an appealing strategy to identify persons who may benefit from referral to a mental health professional to resolve their symptoms. The benefits of routine screening in the context of HIV care include time and cost efficiency, as well as the ease with which screening instruments may be administered. For example, a clerk or clinic receptionist at an HIV clinic may hand the screening questionnaire to a patient on arrival at the clinic. In such a scenario the patient may complete the questionnaire, hand it to the attending clinician, who then sums the scores and makes a determination about whether referral to a mental health professional is warranted. Such an approach may increase the likelihood of case-finding in the context of a busy public health clinic, especially in low- and middle-income countries (LMICs) where the ratio of clinicians to patients is typically low. To determine the presence of a common mental disorder by means of a diagnostic interview may be more accurate as a trained clinician is able to apply their clinical judgment to determine the presence and severity of each symptom. However, integrating diagnostic interviews into routine care is resource intensive. Salaries for trained mental health professionals can be costly, confidential office space is needed, and sufficient time is required to conduct an interview to allow the clinician to arrive at diagnostic impressions. These resources may be difficult for public health systems to procure under conditions of scarcity, which is characteristic of low and middle income countries.
In this cross-sectional study we assessed the ability of the PTSD Checklist for the DSM-5 (PCL-5) to distinguish between caseness and non-caseness for posttraumatic stress disorder among South Africans receiving HIV care. The PCL-5 and the Structured Clinical Interview for the DSM5 Research Version (SCID-RV) module for PTSD were administered to 688 patients receiving antiretroviral therapy (ART) at two HIV care clinics in the greater Cape Town area. Of the total sample, nearly half of our participants (47.1%) reported experiencing an index traumatic event and 14.74% met the diagnostic criteria for PTSD as measured by the SCID-RV. We used receiver operating characteristic curve analysis to determine that a cut-point of 32 on the PCL-5 was useful in yielding an optimal combination of sensitivity and specificity.  Using this cut-point the PCL-5 was effective in determining caseness for PTSD 88% of the time, and non-caseness 88% of the time. The area under the curve (AUC) was 94.3% indicating high accuracy. The positive and negative value predictive were 56.3% and 97.7%, respectively, which suggests that the PCL-5 is an effective screening instrument to determine the presence of PTSD among South African ART users. 
We believe these findings are important as the PCL-5 may be used to identify persons who have symptoms of traumatization so that they may be referred for treatment. Undetected and thus untreated PTSD may reduce quality of life, impede optimal adherence to ART, and increase the likelihood of risk behaviors among persons living with HIV, thus contributing to further infections. Persons treated for PTSD are more likely than those who are undetected and untreated to: experience a reduction in psychological distress; enjoy a better quality of life; experience greater satisfaction in interpersonal relationships; and be more adherent to their antiretroviral therapy regimens. Those ART users who are adherent to their medication regimens usually have a suppressed viral load and thus have less vulnerability to opportunistic infections, require fewer hospitalizations, and enjoy a longer lifespan compared with non-adherent persons.

Reference Article 

Kagee, A., Bantjes, J., Saal, W., & Sterley, A. (in press). Predicting caseness of posttraumatic stress disorder using the PTSD Checklist for the DSM-5 (PCL-5) among patients receiving HIV careJournal of Traumatic Stress. 

Discussion Questions

  • Is screening for posttraumatic stress useful in the context of HIV care?
  • Does screening for posttraumatic stress lead to improved mental health outcomes?
  • What are the limitations of the study beyond what have been identified in the paper?

About the Authors

Ashraf Kagee, PhD., MPH
,  is Distinguished Professor of Psychology at Stellenbosch University, co-Director of the Alan Flisher Centre for Public Mental Health and Chairperson of the Board of Trustees of the Trauma Center for Violence and Torture in South Africa. He can be contacted at skagee@sun.ac.za.
Dr Adélle Sterley, MB.ChB
is employed by Department of Health as a full time Medical Officer.  She is head of the department of Infectious Diseases at the Outpatient Department, Helderberg Hospital, Somerset-West in South Africa. Dr. Sterley can be contacted at adellesterley@gmail.com
Dr. Wylene Saal 
is a postdoctoral research fellow at the Centre for Social Science Research, University of Cape Town. She is a quantitative investigator on the HEY BABY study on adolescent mothers and their children. She holds a PhD in Research Psychology from the University of Stellenbosch, where her research focused on common mental disorders (i.e. major depression, generalized anxiety disorder, and alcohol use disorder) among people seeking HIV testing in the Western Cape. Her research interests include adolescent mental health, HIV, research methodology and health psychology. 
Twitter: Wylene Saal (@saal_wylene).
Dr. Jason Bantjes
is Associate Professor of Psychology in the Institute for Life Course Health Research at Stellenbosch University.  He can be contacted at jbantjes@sun.ac.za.