To our knowledge, this is one of the first population-based studies to examine the prevalence of depression and to systematically explore gender-specific correlates of depression in a high prevalence HIV setting in sub-Saharan Africa. We found that over 30% of men and 25% of women in the five regions surveyed in Botswana screened positive for depression, which is between two and four times the prevalence found in the United States 
. These findings are consistent with several other smaller studies in the region where HIV prevalence is also high; 21% of individuals in a small study in Uganda and 31% of individuals from a small study in Zimbabwe screened positive for depression 
. A population-based study in South Africa and another in Zambia found prevalence of depression between 5–15% 
. These results underscore our need to better screen for and treat depression within Botswana and in other settings with a high prevalence of HIV. Our finding that men had a higher prevalence of depression compared to women differs from prior studies in the region that had found either no differences in the prevalence of depression by gender or a higher prevalence among women 
. Potential explanations for this finding are that compared to women in this region, men often have less social support 
and access healthcare less frequently 
, which have been shown to be correlated with depression in prior literature from low resource settings including among PLWHA 
Earlier studies on correlates of depression in sub-Saharan Africa have focused primarily on socio-demographic factors. Our findings on socio-demographic correlates were similar to those found in literature from both resource-poor and resource-rich settings. We found that lower educational status among women and being unmarried among men were associated with depression, similar to previous studies 
. Additionally, we saw a trend towards an association between depression and both unemployment 
and food insufficiency 
as previously reported in studies from resource poor and rich countries. We found that women with higher incomes had a higher prevalence of depression. This finding contrasts with some previous studies that have reported the converse 
but corresponds to findings among specific US subpopulations (e.g. obese women) 
. Men from rural areas in Botswana had greater odds of depression, consistent with a prior study from Ethiopia 
Our study highlights associations between depression and increased healthcare utilization and worse clinical outcomes, which can be useful to guide future studies in the region. Similar to prior studies, we found that depression was associated with increased frequency of visits to health providers among men 
, suggesting the need to screen for and treat depression among frequent users of health care services. We also saw a trend towards an association between depression and having fair/poor self-reported health status among women, which has been predictive of developing chronic disease and mortality in other studies 
. It is possible that depression is a marker for having chronic medical conditions, which in turn can lead to increased health utilization. Further studies are needed to explore the direction of this association and address potential mediators.
Depression has been identified as a major contributor to sexual risk behavior and HIV infection in studies from the US 
and a few smaller studies in South Africa 
. Our study is one of the first to find an association between depression and various risky sexual practices in a nationally representative sample in sub-Saharan Africa. We tested four components of risky sexual behavior and found that, among women, lack of control in sexual decision-making correlated with depression in adjusted analysis. Previous research from this region has demonstrated that women experience power inequities, lack of negotiating power and compromised agency within sexual relationships. This finding is consistent with previous research conducted in South Africa that found that having joint-decision making power in relationships is associated with lower odds of depression 
. In a culture where sexual violence is pervasive with six of 10 women being lifetime survivors of domestic violence, this may reflect social constructs of gender that legitimize potential victimization of women leading to feelings of lower self-worth among women and a higher prevalence of depression. In addition to leading directly to depression, it is also plausible that lack of sexual control can indirectly lead to depression via engaging in risky sex if people do not feel good about their choices and practices. A final possibility is that women who are depressed feel less empowered to assert control over their sexual relationships. Due to the cross-sectional nature of this study, were unable to fully tease apart the complexity of the relationships between lack of control in sexual decision-making and depression. Future studies should use validated measures of sexual relationship control and longitudinal study designs to determine the direction of these associations, and the factors that may mediate these relationships.
Among men, we found that having intergenerational sex correlated with depression in adjusted analyses. Having intergenerational relationships may be a marker of inequitable gender beliefs and practices 
, and intergenerational sex in turn has been associated with sexual violence and sexual risk-taking behavior in many studies 
. Since intergenerational relationships have been reported to increase male self-esteem and social standing 
, it is possible that depression may make men more likely to seek out intergenerational sexual relationships. Our findings highlight the need to target depression as part of HIV prevention efforts and also suggest that addressing gender power imbalances may decrease depression among both men and women.
Our study is one of the first to demonstrate a strong association between anticipated HIV stigma (the respondent's expectation that he or she would be stigmatized for having HIV) and depression in a resource-poor setting. We found this association among men and a trend towards an association with depression among women. Several small studies from sub-Saharan Africa have reported correlations between depression and enacted stigma (experiencing discrimination) or internalized stigma (attributes discredited by society become internalized and accepted as valid by PLWHA) 
, measures that are typically used in studies where HIV status of participants are known. Our findings are unique since we measure HIV stigma at a nationally representative population level in Africa where the burden of HIV stigma is so great 
, and also because we are the first to report an association between anticipated HIV stigma and depression in the general population. In the country with the second to highest HIV prevalence in the world, it is not difficult to imagine why anticipating negative responses to HIV could contribute to symptoms of depression among the general population. Both depression and HIV stigma have in turn been associated with poor physical and mental health outcomes and increased risk of HIV transmission 
. Therefore, the association between anticipated HIV stigma and depression further strengthens the rationale for targeting HIV stigma as part of comprehensive HIV prevention and care programs.
There were a few important limitations to this study. Since the design of the study was cross-sectional, we cannot draw conclusions about the directionality of the associations between the variables. This study was intended to be hypothesis generating to guide future studies. Since we did not interview individuals from more rural districts of Botswana and since Botswana has a relatively high per capita income and comparatively extensive healthcare infrastructure, we can not necessarily generalize these results to neighboring countries. We used self-reported responses, which may lead to social desirability bias. However under-reporting of some risky sexual behaviors and other practices would bias results toward the null hypothesis, so true associations may be stronger than our data indicate. Additionally, participant HIV status, a health factor that may affect mental health, health practices and economic status, was not asked directly in our interviews. Our measure of depression is based on a screening tool for depression and not a diagnostic tool. Finally, we do not account for severity of depression since the HSCL-D tool does not allow for clinically meaningful separations in depression severity. The direction of effect between depression and risky sexual practices may depend on the severity and type of depression. For example, a prior study showed that major depression was correlated with less sexual activity, while dysthymic disorder was associated with increased unprotected sex 
. Further research will be needed to evaluate variation in correlates of depression based on depression severity. Additionally, variables including lack of control in sexual decision-making, intergenerational sex, and HIV-related stigma have complex social constructs and will require additional study to fully understand their associations with depression.
In summary, we found that depression is highly prevalent in Botswana, and its correlates are gender-specific. Our findings suggest multiple targets for screening for and preventing depression and highlight the need to integrate mental health counseling, screening, and treatment interventions into primary health care. Treatment options for depression are currently limited in Botswana with few primary care providers trained to detect psychiatric disorders. Nonetheless, depression is a treatable condition and interventions using either antidepressants or psychotherapy can be successful and inexpensive in resources-low settings 
. Treatment of depression will likely lead to less transmission of HIV and improved outcomes for those already infected.