The Relationship Between Mental Health and HIV in Conflict-Affected Settings: A Focus on the Democratic Republic of Congo

Background Conflict-affected populations are at risk for poor mental health, and multiple factors, such as sexual violence, can increase or decrease risk for HIV in conflict-affected settings. The relationships between mental health and HIV in conflict-affected settings have not been fully explored. Protracted conflict in eastern Democratic Republic of Congo (DRC), with its high rates of sexual violence, makes it an important setting in which to examine these relationships and possible programmatic responses. Methods Manuscript 1 systematically reviews the literature on relationships between mental health disorders (depression, anxiety, and post-traumatic stress disorder [PTSD]) and HIV (including HIV-positive serostatus, and factors associated with HIV acquisition and progression) in conflict-affected settings globally. Manuscript 2 uses multiple logistic regression to examine the associations between mental health disorders (depression, anxiety, and PTSD) and having been treated for a sexually transmitted infection (STI), a marker for HIV risk, in eastern DRC. Manuscript 3 uses qualitative interviews to examine how solidarity groups – a community-based medical, psychosocial, and economic support intervention – affect mental health for female survivors of conflict-related sexual violence in eastern DRC. Results The systematic review included 25 out of 550 identified publications and found that symptoms of poor mental health were associated with increased HIV-associated risk factors (sexual risk behaviors) and HIV markers (STIs). HIV risk exposures (sexual assault) and health status (HIV-positive serostatus and CD4 count) were also associated with poor mental health in conflict-affected settings. In the DRC, individuals who were symptomatic for depression and anxiety (adjusted odds ratio [OR]=2.73, 95% confidence interval (CI): 1.68, 4.44), and PTSD (adjusted OR=1.89, 95% CI: 1.17, 3.06) were more likely to have been treated for an STI than those who were not symptomatic. Qualitative interviews suggested that solidarity groups have the potential to improve the mental health, physiological, economic, and social aspects of sexual violence survivors’ lives. The most common symptoms described by women were mawazo (constant thoughts or worries), kukosa usingizi (missing sleep), and woga (fear). Conclusions Existing evidence suggests important relationships between poor mental health and HIV in conflict-affected settings globally. In eastern DRC, poor mental health is associated with STI treatment and has been reported by women who have experienced conflict-related sexual violence, although interventions such as solidarity groups may help to mitigate these mental health challenges. Future research should assess the magnitude and causality of relationships between poor mental health and HIV in conflict-affected settings and examine the effectiveness of solidarity groups on key mental health outcomes