Gay men, regardless of their HIV status, with chronic, low-grade depression are significantly more likely to have unprotected sex with a casual partner, according to an Australian study published in the September edition of HIV Medicine. The study also found, however, that men with a major depression, were less likely to report unprotected anal sex.
There are conflicting data about the impact of depression on sexual risk taking by gay men. These studies have not, however, distinguished between major depression, which is characterised by a significantly depressed mood for at least two weeks, along with reduced interest and pleasure and certain other serious symptoms, and dysthymic disorder. This condition is a less severe, but chronic form of mild depression, and is diagnosed when a person has experienced low mood for the majority of the time over two years.
Investigators involved in the South Australian Care and Prevention Programme sought to establish if major depression and dysthymic disorder had distinct effects on sexual behaviour.
A total of 460 gay men receiving primary care were recruited to the study between 1998 and 2001. The majority were recruited from a general practice with a special interest in the healthcare of gay men. All the men completed a self-administered questionnaire designed to identify major depression and dysthymic disorder. Further questionnaires gathered data on sexual behaviour, demographic details, medical history, and HIV-specific health information of the positive study members.
Of the 460 gay men in the study, 162 (35%) were HIV-positive, 283 (62%) were HIV-negative and 15 (3%) were untested. Median age was 39 years, almost all the men were Caucasian, 53% were employed (significantly less than the 80% employment rate for the region, p<0.001). The HIV-positive men had significantly lower incomes than the adult male average, whilst the HIV-negative men had slightly lower incomes. Anti-HIV therapy was being used by 73% of HIV-positive individuals, with 87% taking HAART.
Unprotected anal sex, insertive or receptive, with a casual partner in the previous six months was reported by 14% of men. HIV-positive men were significantly more likely to report casual unprotected anal sex than HIV-negative men (19% versus 12%, OR 1.66, 95% CI: 0.97 – 2.84, p=0.068).
Major depression was diagnosed in 28% of men, and 26% of men met the diagnostic criteria for dysthymic disorder. This prevalence included 84 men who were diagnosed with both disorders and had ‘double depression.’ Identical proportions of HIV-positive and HIV-negative men had major depressions and dysthymic disorder,
In initial analysis, no association was found between dysthymic disorder and casual unprotected sex. As a major depression can cause reduced libido, the investigators repeated their analysis excluding men with major depression. This revealed that men who had chronic, low-grade symptoms of depression without a current major depression were significantly more likely to report unprotected sex with a casual partner (OR 2.36, 95% CI:1.09 – 5.10, p=0.035).
In univariate analysis HIV-positive men with dysthymic disorder were more likely to report unprotected casual sex, as were men who drank excessively, used poppers, took speed, or injected drugs. In multivariate analysis, however, only dysthymic disorder (OR 2.32, 95% CI: 1.02 – 5.24, p=0.044), current poppers use (OR 2.24, 95% CI: 1.21 – 4.16, p=0.010) and injecting drug use (OR 3.76, 95% CI: 1.14 – 12.48, p=0.030) remained significantly associated with risk behaviour.
The investigators note that compared to the general Australian population, gay men in this study were significantly more likely to report either a major or chronic low-grade depression.
Low-grade, long-term depression, appears to be a factor, say the investigators, which prevents gay men from translating HIV prevention knowledge into “protective behaviour.”
”It is not difficult to understand that gay men who have been stigmatized for much of their lives, and who have lived through the devastation of their community by HIV, may sometimes find themselves in a psychological state where they ‘just don’t care’ about protecting themselves or others” observe the investigators. They add that dysthymic disorder “may be the diagnostic representation of such a mental state and since the condition” is potentially treatable “it warrants careful consideration in the prevention of HIV at individual and population levels.”