o cto b e r 2 0 0 9 T H E S O U T H E R N A F R I C A N J O U R N A L O F H I V M E D I C I N E

Post-traumatic stress disorder (PTSD) is a complex psy-
chological and physiological response to serious, life-
threatening trauma. The prevalence of PTSD in HIV-
infected individuals varies across studies, ranging from
30% to 64%4-6 depending on the various methods of
assessment, sample characteristics and diagnostic cri-
teria used. In one South African study of recently diag-
nosed HIV/AIDS patients (N=149), 14.8% met current
criteria for PTSD at baseline, and 26.2% met criteria at
6-month follow-up.7,8 Rates of PTSD appear to be sig-
nificantly higher among HIV-infected individuals than
in the general population.

Many studies show that a history of trauma, partic-
ularly physical and sexual abuse, is common among
HIV-positive individuals and exceeds that in the gen-
eral population.9 In one study in the USA, 95% of the
women in primary care had experienced some form of
sexual abuse in their lifetime, and 83% had experienced
significant physical abuse.10 Another study found that
72.5% of the participants had experienced at least two
types of traumatic events during their lifetime, and
53.5% had some sexual and/or physical abuse history
in their lifetime.11 The association between HIV infec-
tion and trauma exposure may be causal (for example,
childhood sexual abuse has been linked to higher rates
of sexual and drug use risk behaviours that increase
the risk of HIV) or may reflect of the concentration of

HIV infection in socio-economically deprived popula-
tions who are at high risk of trauma exposures.12

Traumatic life events, especially multiple traumatic
events, are strongly associated with poorer treat-
ment adherence, HIV risk behaviours, a history of al-
cohol abuse and depression, more hospitalisations,
and faster HIV disease progression.9,11-14 Furthermore,
there is a dose-response relationship with the odds of
non-adherence to antiretroviral therapy (ART) increas-
ing with each additional lifetime traumatic exposure.14
Prior trauma may affect adherence through a variety
of pathways, including: (i) PTSD or other mental health
problems (as well as substance misuse); (ii) subjective
experiences of and trust in the health care system; (iii)
individual coping styles and self-efficacy mechanisms;
and (iv) the availability of social support.14,15

There are essentially three core aspects to consider in
the assessment for PTSD in people living with HIV/AIDS
(PLWHA): (i) identification of patients who are pre-
disposed to the disorder (i.e. at risk); (ii) careful as-
sessment of all traumatic events that a patient has
experienced; and (iii) understanding of the diagnostic
criteria for PTSD.

HIV-infected patients with PTSD can present a special
challenge to the primary care physician as they com-

THE MANAGEMENT OF TRAUMA AND POST-
TRAUMATIC STRESS DISORDER IN HIV-

INFECTED INDIVIDUALS

c l i n i c a l : p t s d

Janine Pingo, MB ChB
Lentegeur Hospital, Mitchell’s Plain, Cape Town

Soraya Seedat, MB ChB, FC Psych, MMed Psych (US), PhD
Department of Psychiatry, Stellenbosch University, Tygerberg, W Cape

Women are disproportionately affected by the HIV epidemic and also carry a higher burden of early childhood
trauma, other life traumas (e.g. rape and partner violence) and post-traumatic stress disorder (PTSD).1,2 Yet
PTSD and other common psychiatric disorders (e.g. depression, alcohol abuse) are commonly under-detected in
HIV care settings. For many HIV-infected individuals in South Africa, HIV clinical care is the primary point at
which mental illness can be identified and an intervention can be administered.3 When one considers the high
prevalence of trauma and PTSD in infected patients, and its potential effects on antiretroviral therapy (ART)
adherence, disease progression and quality of life, it is clear that correctly identifying and treating these condi-
tions can significantly contribute to optimal patient care.

HiV, tRaUMa and ptsd intERFacE

assEssMEnt OF tRaUMa and ptsd

T H E S O U T H E R N A F R I C A N J O U R N A L O F H I V M E D I C I N E o cto b e r 2 0 0 9

monly complain of vague somatic symptoms that may
be the somatic expression of their disorder, be exac-
erbated by their PTSD, or be unrelated.16 Patients with
PTSD also suffer from psychiatric co-morbidities such as
depression, other anxiety disorders and substance abuse.
Many patients use alcohol or drugs in an attempt to
self-medicate their PTSD symptoms. In addition, patients
with PTSD are at an increased risk of gastro-intestinal,
cardiac, respiratory and neurological problems.17

Risk factors in both infected and uninfected individuals
associated with the development of PTSD are listed in
Table I.

In PLWHA, additional factors such as stigma may be
contributory. For example, a study of 102 HIV-infected
women that examined risk factors for PTSD symptoma-
tology found that PTSD was associated with a higher
degree of perceived stigma, more HIV-related physical
symptoms, less perceived social support, more pre-HIV
trauma, and more negative life events.19 Stigma was
the strongest individual predictor of PTSD, which high-
lights its importance in assessing for PTSD co-morbid-
ity in infected individuals.

PLWHA who have PTSD are typically unaware of the
connection between a past traumatic experience and
their current symptoms. At the same time, primary care
physicians are often reluctant to ask about trauma for
fear of upsetting or offending patients or because of
their own discomfort around hearing patients’ trauma
narratives. Asking HIV-positive patients about trauma
with a simple question such as ‘Have you ever been
physically, sexually or emotionally harmed?’ may be
useful in helping patients understand the relationship

between trauma and its effects (i.e. in providing psy-
cho-education), eliciting any underlying disorder/s, and
then managing patients appropriately.16

There are six criteria (A - F) for the diagnosis of PTSD
according to the Diagnostic and Statistical Manual of
Mental Disorders, 4th edition, text revision (DSM-IV-
TR).20 Criterion A defines the PTSD-qualifying event/
stressor as one that involves actual or threatened death
or injury and evokes a response of intense fear, hor-
ror or helplessness. Traumatic events that give rise to
PTSD include childhood abuse, rape, domestic violence,
violent physical assault, motor vehicle accidents, mili-
tary combat, and natural and man-made disasters.20
Although being given a diagnosis of a life-threatening
disease such as HIV may be considered as ‘traumatic’,
there is some controversy about whether it classifies as
an event that is capable of giving rise to PTSD.21,22

It is crucial to ask patients whether a traumatic ex-
perience is ongoing or in the past (e.g. ‘Is this dan-
gerous/life-threatening experience continuing in your
life now?’).16 This should be followed up with questions
including ‘Some people who have had extremely trau-
matic experiences develop symptoms (e.g. nightmares,
sleep disturbances, flashbacks) like the one you de-
scribe’, or ‘Some people who have had traumatic expe-
riences like you also have symptoms of ... [e.g. chronic
pain]. Have you ever thought that there might be a
connection between your traumatic experience and
your symptoms?’16

Criteria B - D refer to the three symptom clusters of
PTSD: intrusive recollections, avoidance/numbing, and
hyper-arousal. Intrusive recollections include recurrent
distressing memories and nightmares of the event, act-
ing or feeling as if the traumatic event were recurring,

pre-traumatic factors
• Previous psychiatric disorder
• Female gender
• Personality (external locus of control greater than internal locus of control)
• Lower socio-economic status
• Lack of education
• Minority status/race*
• Previous trauma
• Family history of psychiatric disorders

peri-traumatic factors
• Severity of trauma
• Perceived threat to life
• Peri-traumatic emotions
• Peri-traumatic dissociation

post-traumatic factors
• Perceived lack of social support
• Subsequent life stress

*The effect of race/minority status has been documented primarily in US samples.

taBlE i. FactORs assOciatEd WitH tHE dEVElOpMEnt OF ptsd18

RisK FactORs FOR ptsd

tRaUMatic liFE EVEnts

tHE dsM-iV cRitERia FOR ptsd

o cto b e r 2 0 0 9 T H E S O U T H E R N A F R I C A N J O U R N A L O F H I V M E D I C I N E

and intense psychological and physiological distress on
exposure to internal or external cues that remind one
of a certain aspect of the event.

Avoidance/numbing symptoms refer to avoiding
thoughts, feelings, conversations, activities, people or
places that arouse recollections of the trauma, inability
to recall important aspects of the trauma, lack of inter-
est or participation in significant activities, feelings of
detachment from others, restricted range of affect, and
a sense of a foreshortened future.

Hyper-arousal symptoms include difficulty falling or
staying asleep, irritability or outbursts of anger, diffi-
culty concentrating, hyper-vigilance, and an exagger-
ated startle response.

Criterion E refers to the duration of the symptoms (last-
ing more than 1 month), and criterion F refers to the
functional significance of symptoms (whether there is
clinically significant distress or impairment in social,
occupational or other important areas of functioning).

Lastly, one needs to specify whether the symptoms are
acute (less than 3 months) or chronic, and whether
symptom onset is delayed (onset of symptoms at least
6 months after the trauma).

While a detailed diagnostic interview such as the Clini-
cian Administered PTSD Checklist (CAPS) is the ‘gold
standard’, such an interview is lengthy and may be
impractical for use in primary care settings. Brief and
simple-to-complete screening tools may be more fea-
sible. The four-item Primary Care Post-Traumatic Stress
Disorder screen (PC-PTSD) is one such measure that as-
sesses symptoms specific to the core domains of PTSD.23
The PC-PTSD asks the patient ‘In your life have you ever
had any experience that was so frightening, horrible or
upsetting that, in the past month, you ...’

n Have had nightmares about it or thought about it
when you did not want to

n Tried hard not to think about it or went out of your
way to avoid situations that reminded you of it

n Were constantly on guard, watchful, or easily star-
tled

n Felt numb or detached from others, activities or your
surroundings.

Three or more ‘yes’ responses to these questions is
highly suggestive of PTSD, requiring further evaluation
of symptoms and other trauma-related problems by a
mental health care practitioner if need be. A cut-off
of 3 on the PC-PTSD yields a sensitivity of 78% and
specificity of 87% compared with the gold-standard

CAPS.23 The PC-PTSD is simple to administer and may
be easily used in a busy clinical setting alongside the
SA-MISS (see related article in this issue on common
mental disorders in HIV).

PLWHA who have PTSD are often fearful and highly
sensitive to physical sensations (e.g. a physical exami-
nation can remind some patients of their traumatic ex-
perience), and in turn may be ambivalent about medi-
cal treatment. Being supportive, enhancing a sense of
personal safety, and recommending self-care strategies
(e.g. an activity that is enjoyable and self-fulfilling) can
help patients manage their anxiety and reduce risk-
taking and self-destructive behaviours.

In clinical practice, the majority of adults with PTSD
derive most benefit from a combination of treatment
approaches encompassing psychopharmacology and
psychotherapy.17 The management principles discussed
below are illustrated in the form of a case study (see
box).

pHaRMacOlOGical tREatMEnt
Medication has been shown to be significantly more
effective than placebo across all three symptom clus-
ters in PTSD, and has also been shown to be effective in
reducing co-morbid symptoms and improving quality
of life.24-30 Medication should be considered from the
beginning if the patient prefers it, if the symptoms are
severe and persistent, if there is co-morbid depression
and anxiety, and if functioning is severely disrupted.
PLWHA who have PTSD may be highly sensitive to
physical symptoms and to medication side-effects. Ad-
herence may be enhanced by starting medication at
low doses with gradual increases based on tolerability.

n selective serotonin reuptake inhibitors (ssRis)
are the most studied medications for PTSD and are
widely considered as first-line agents for this con-
dition. In South Africa fluoxetine is easily available
and can be used as a first-line agent. SSRI treatment
is most helpful in the long term if it is continued
for at least 12 months after remission of symptoms.
More on the use of SSRIs can be found in the article
on psychotropic prescribing in HIV infection.

n if there is no response in 8 weeks, the primary care
physician should refer the patient for psychiatric
care. Further indications for referral to specialised
psychiatric care are shown in Table II.31

n Benzodiazepines should be avoided or used with
caution. While they reduce anxiety and promote
sleep, controlled trials have not shown them to
be superior in efficacy to placebo; with the risk of
drug dependence, benzodiazepines are not recom-
mended.

scREEninG

ManaGEMEnt OF ptsd

o cto b e r 2 0 0 9 T H E S O U T H E R N A F R I C A N J O U R N A L O F H I V M E D I C I N E

psYcHOlOGical tREatMEnts
Psychological treatments are widely used to treat PTSD
as they have been shown to significantly reduce symp-
toms.32 All patients willing to attend should be referred
for psychological treatment, depending on the avail-
able services. Trauma-focused cognitive-behavioural
therapy (CBT) is recommended as it has been exten-
sively studied in PTSD.33 CBT consists of anxiety man-
agement (teaching patients skills to cope with stress,
such as relaxation training, breathing training, assert-
iveness training, etc), cognitive therapy (modifying un-
realistic assumptions, beliefs and automatic thoughts),
and prolonged exposure therapy (learning to confront
situations associated with the trauma).25

sUppORtiVE intERVEntiOns
When a patient has recently experienced an extreme-
ly traumatic event, time should be taken to educate
the patient and his or her family about acute stress
reactions and PTSD, and to reassure the patient that
it is normal to be upset and distressed shortly after a
trauma. The family should be encouraged to talk about
the traumatic event with the patient and provide the
necessary support, where possible.33 In instances of do-
mestic violence, for example, the physician will need to
assess whether reporting is required and should inform
the patient of the limits of confidentiality. Involvement
of social workers should be considered to ensure that
ongoing abuse does not occur.

REFEREncEs

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casE stUdY
A 26-year-old HIV-positive woman with a CD4
count of 180 cells/µl is referred to her local ARV
clinic to initiate antiretroviral therapy. In the ini-
tial interview the HIV clinician notices that she
appears to be a little anxious and withdrawn, and
seems tired.
The patient says that she was diagnosed with HIV
3 years ago after she was sexually and physically
abused by her boyfriend at the time. A year ago
she left her family and friends in the Eastern Cape
to find work in Cape Town. She has Grade 10 ed-
ucation, and is currently a casual employee at a
fast-food restaurant and living with a friend.

The HIV clinician becomes concerned, as this pa-
tient has a history of previous trauma, comes from
an impoverished background and has little social
support, and enquires further about her symptoms
of anxiety and tiredness. The patient says that
about 2 months ago she was mugged on the way
home from work, physically assaulted and threat-
ened with a knife. Since then she’s had difficulty
sleeping, occasionally experiences nightmares of
the event, can’t recall certain aspects, feels con-
stantly on guard, and feels as if her emotions are
numbed. She has taken a number of days off work
recently as she’s afraid she will be mugged again,
and her supervisor has already warned her that
she may lose her job.

The HIV clinician makes the diagnosis of post-
traumatic stress disorder, and explains the treat-
ment options available. At the patient’s request,
fluoxetine 20 mg daily is prescribed and a refer-
ral is made to the clinic psychologist to initiate
cognitive-behavioural therapy. The patient is also
started on ARVs and warned of possible side-
effects, and regular follow-up is arranged to mon-
itor her progress.

• If the patient has other serious psychiatric problems which are not improving on treatment
• If the patient has suicidal thoughts/behaviour
• If there are persistent problems with medication side-effects
• If PTSD symptoms are not responsive to an adequate trial ((8 weeks at an average therapeutic dose) of at least one

medication
• If there are co-existing substance abuse problems
• If the patient is experiencing other life stressors and/or poor social support

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