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Background It is not known whether post-traumatic stress disorder (PTSD) increases HIV-risk behaviours among young people in sub-Saharan Africa. We assessed associations of PTSD symptoms with sexual behaviour, HIV risk perception, and attitudes towards PrEP among young people taking part in the CHAPS community survey. We hypothesised that PTSD symptoms would increase sexual behaviours associated with HIV risk, hinder PrEP uptake and influence preference for daily versus on-demand PrEP. Methods Young people without HIV, aged 13–24 years, were purposively recruited in Johannesburg and Cape Town in South Africa, Wakiso in Uganda, and Chitungwiza in Zimbabwe, and surveyed on socio-demographic characteristics, PrEP knowledge and attitudes, sexual behaviour, HIV perception and salience, and mental health. PTSD symptoms were measured using the Primary Care PTSD Screen for the Diagnostic and Statistical Manual of Mental Disorders 5 (PC-PTSD-5). Logistic and ordinal logistic regression was used to assess associations between PC-PTSD-5 score and socio-demographic characteristics, sexual behaviour, HIV risk perception, PrEP attitudes, and substance use, adjusting for age, sex, setting, depression and anxiety. Results Of 1330 young people (51% male, median age 19 years), 522 (39%) reported at least one PTSD symptom. There was strong evidence that having a higher PC-PTSD-5 score was associated with reported forced sex (OR 3.18, 95%CI: 2.05–4.93), self-perception as a person who takes risks (OR 1.12, 95%CI: 1.04–1.20), and increased frequency of thinking about risk of HIV acquisition (OR 1.16, 95%CI: 1.08–1.25). PTSD symptoms were not associated with willingness to take PrEP, preference for on-demand versus daily PrEP, or actual HIV risk behaviour such as condomless sex. Conclusions Symptoms consistent with probable PTSD were common among young people in South Africa, Uganda and Zimbabwe but did not impact PrEP attitudes or PrEP preferences. Evaluation for PTSD might form part of a general assessment in sexual and reproductive health services in these countries. More work is needed to understand the impact of PTSD on HIV-risk behaviour, forced sex and response to preventive strategies including PrEP.

We and others have previously reported reduced mortality and malaria incidence with cotrimoxazole prophylaxis for HIV-1-infected adults in Uganda and elsewhere. This evidence has led to widespread implementation of cotrimoxazole prophylaxis for HIV-1-infected persons in sub-Saharan Africa. The World Health Organization (WHO) recommends that implementation at the country level should be carefully monitored and that this monitoring should evaluate rates of toxicity including hematologic toxicity through the measurement of blood cell counts every 6 months. Cotrimoxazole interferes with folate metabolism and there have been several reports of hematologic abnormalities associated with its use. These abnormalities could potentially worsen if cotrimoxazole is used in conjunction with myelosuppressive or antifolate drugs such as zidovudine. There is scanty evidence of these abnormalities associated with cotrimoxazole use in Uganda however. Cotrimoxazole prophylaxis was introduced in August 2000 in an open cohort of HIV-1-infected participants in EntebbeUganda. Here we report hematologic changes in participants before and after the introduction of cotrimoxazole. (excerpt)