Poor mental health may be a factor in becoming HIV positive and after diagnosis it may be a factor in both the risk of contracting other STIs and of transmitting HIV. The decision to engage in risky sex may not always be a consciously made decision, but an attempt to satisfy some other need.

Firstly, anxiety and depression may be risk factors in themselves. One Australian study already cited (Rogers) found that gay men with dysthymia (but not major depression) were 2.36 times more likely to have unprotected sex.

A study from Connecticut (Kozal) found an even stronger association between mental distress and unsafe sex. The researchers interviewed 333 HIV positive people (of all genders and sexualities) about their risk behaviour over the previous three months. Of these, 23% (75 people) had had unprotected sex with 191 separate partners, only 36 of whom (19%) were known to be HIV positive themselves. About 5% of the clinic attendees were responsible for most of the unprotected sex with casual partners. There was no relationship between unprotected sex and any physical measurement such as viral load, CD4 count or HIV symptoms, nor with demographic variables such as race. Gay men had more unsafe sex because they had more partners. Once the influence of number of partners was factored out, so that the choice of whether or not to have protected sex was the only variable left, the only predictor of whether people chose to have unsafe sex was a higher mental distress score of a scale that measured depression and anxiety. People in the highest quartile of poor mental health scores were ten times more likely to choose to have unprotected sex than others.

In another study among gay men (Martin) social isolation was associated with sexual risk taking. A sample of 470 urban gay men completed a self-administered questionnaire. Participants scored high on loneliness in comparison to matched group of non-gay men and men who had unprotected anal intercourse with casual partners during the previous six months scored higher on Loneliness than other participants, but those who did so with primary partners scored the lowest. The researchers comment that “Episodes of unprotected anal intercourse with nonprimary partners might have been avoidance strategies to help participants cope with loneliness or other negative affect.” In other words, loneliness may not just lead gay men to go out and have casual sex, it may also be a driver behind unsafe sex, as this comes to symbolize contact and satisfies a craving for it.

For many gay men, low self-esteem and internalized homophobia can impact HIV risk-taking. One study (Ross) linked internalized homophobia directly with increased risk of having HIV. Two hundred and two gay men attending sexual health seminars in Houston, Texas filled in questionnaires assessing how much they were out as gay, whether they enjoyed the company of other gay men, whether they had religious and moral views about the acceptability of being gay, and the degree to which they felt stigmatised. People with higher degrees of internalised homophobia were more likely to have HIV.

In one particularly interesting study of gay men (Imrie) 408 gay men with HIV attending the HIV clinic at the Royal Free Hospital in north London were surveyed to see if they had had an STI over the last 12 months and were then asked about four types of experience that other studies have shown are associated with high levels of sexual risk taking and poor mental health. They were asked if they’d started having sex below the legal age of consent (16 in the UK); whether they’d even been forced to have sex; whether they’d ever been paid for sex; and whether they had ever injected drugs, including performance steroids.

The researchers found that 125 or nearly one in four of the HIV patients (23.5%) had been diagnosed with an STI during the previous year.

Out of the whole patient group, whether they had had an STI or not, they found that 63% had first had sex before they were 16; over a third (36%) had been paid for sex at some time; over a quarter (27%) had had an experience of non-consensual sex; and 12% had injected drugs (including performance steroids) during the last five years.

But the proportions of people with these risk factors were all much higher in the men who had had STIs. Of these men, 77% had had first sex before 16; 45% had ever been paid for sex; a third had had non-consensual sex; and one in six had injected drugs.

Putting it another way, men diagnosed with STIs were a third more likely to report first sex before 16 than those without STIs; 62% more likely to have ever been paid for sex; 42% more likely to have had non-consensual sex; and 80% more likely to have injected drugs. Of patients who reporting injecting drugs in the last five years, more than half had had an STI in the previous year.

The researchers comment that “receiving an HIV positive diagnosis is not the end of the story” when it comes to addressing gay men’s prevention needs. “An individual diagnosed with HIV comes complete with a life history in which the receipt of an HIV positive diagnosis is often simply the climax to a list of negative sexual health experiences, and in which there may also be concurrent psychosocial health problems.

“Factors that may have initially predisposed men to becoming HIV infected are likely to continue to infect their sexual health beyond this point and for many years to come…More effective sexual health promotion for those with HIV infection requires innovative interventions which address individuals’ historical antecedents for their current poor sexual health and risk practices.”

Another study from the Royal London Hospital (Beck) found that gay men (HIV positive and negative) attending a sexual health clinic reported high levels of both unprotected sex with serodiscordant partners (36%) and having had non-consensual sex (26%). Although this study did not find an association between a history of non-consensual sex and current unprotected sex, it did find that unprotected sex was associated both with depression and with “cognitions assessing the controllability or predictability of HIV risk”. In other words if gay men had depression, that depression made them feel fatalistic about whether they caught HIV.

Gay men are not the only group among whom child sexual abuse and premature sexual experience have been associated both with depression and with sexual risk taking.

In a second study from the Royal London Hospital (Petrak) 137 out of 303 women attending the GUM clinic there (45%) reported experiences of child abuse, 26% of them child sexual abuse (CSA). Women who had experienced CSA were more likely to have previous STIs (p=0.0007) and more than one concurrent STI (p=0.004). “Women with a history of CSA reported significantly higher frequency of thought reflecting anticipated negative reaction from partners to suggesting condom use,” say the researchers.

PTSD may be a consequence of CSA or a risk factor for HIV in its own right. In one early study of US army veterans (Hoff – published 1997, but data from 1992), the results indicated that the combination of PTSD and substance abuse increased the risk of HIV infection by almost 12 times over those without either.

Several studies have used qualitative interviewing to model why premature or non-consensual sexual experiences may lead to greater HIV and STI risk. In another early study of gay men (Bartholow – 1994 but data collected 1989-90), 1,001 gay men attending urban STI clinics were interviewed regarding abusive sexual contacts during childhood and adolescence. Sexual abuse was found to be significantly associated with mental health counselling and hospitalisation, recreational drug use, depression, suicidal thought or actions, social support, sexual identity development, HIV risk behaviour including unprotected anal intercourse and injecting drug use, and risk of sexually transmitted diseases including HIV infection. “Data suggest that sexual abuse may have a wide-ranging influence on the quality of life and health risk behaviour of homosexual men,” comment the researchers.

Maureen Miller (1999) developed a model to account for the many ways CSA may lead to increasing sexual risk behaviour among women. She said that CSA could lead directly to sexual risk due to difficulty negotiating sex in adulthood; it could lead to sexual risk due to depression; it could lead to “ initiation of and/or increasing reliance on drug use as a method of coping with the sexual abuse experience”, and lastly that social factors such as social support, and social isolation could also influence risk taking.

Drink and drugs

The mention in several of these papers of drug use as a coping mechanism underlines how early experiences, mental problems and drug use may all combine to create sexual risk.

Remember however that drink and drug use in themselves are not defined as mental illnesses by DSM-IV. There has been an extensive literature in recent years particularly dealing with how drug use in gay men is related to HIV risk and acquisition. The Miller paper reminds us that people may take drugs for all sorts of reasons. They may use them to disinhibit themselves socially in order to meet partners; to heighten sensuality and sexual excitement; or simply because everyone else in their social circle uses them. None of these indicate mental distress, need be problematic or lead to addiction in themselves, or create a greater degree of risk to sexual health. A reminder that high-risk behaviour and drug use do not always go together in gay men came from a widely-publicised study (Clatts) of HIV positive men who arranged HIV-only sex parties (‘poz parties’) in order to have unprotected sex. The researchers found that although the men involved had high lifetime levels of recreational drug use, there was very little use of drugs at the parties themselves.

Problematic drug use and/or HIV acquisition as a result of drug use is more likely when patients are either using drugs to escape mental distress or because drug use has created mental distress. People may use drugs:

• To disinhibit themselves sexually because sex creates anxiety when they are sober.
• To ‘self-medicate’ against anxiety and depression.
• Because drug use itself has led to poor mental health (e.g. ecstasy use leading to depression, methamphetamine to anxiety and paranoia) and the person is caught in a spiral of self-medicating for symptoms cause by their ‘medication’.

This is not the place specifically to look at the interaction between drug use and HIV transmission/acquisition. There is an extensive literature, some of which is covered in sections on drug use and on HIV transmission in this manual.

References

Bartholow BN et al. Emotional, behavioral, and HIV risks associated with sexual abuse among adult homosexual and bisexual men. Child Abuse Negl. 18(9): 747-761, 1994.

Beck A et al. Psychosocial predictors of HIV/STI risk behaviours in a sample of homosexual men. Sex Transm Infect. 79(2): 142-146, 2003.

Clatts MC et al. An emerging HIV risk environment: a preliminary epidemiological profile of an MSM POZ Party in New York City. Sexually Transmitted Infections 81: 373-376, 2005.

Hoff RA et al. Mental disorder as a risk factor for human immunodeficiency virus infection in a sample of veterans. J Nerv Ment Dis. 185(9): 556-560, 1997.

Imrie J et al. More to positive prevention than sexually transmitted infection screening. AIDS 19(15), 1708-1709, 2005.

Kozal MJ et al. Antiretroviral resistance and high-risk transmission behavior among HIV-positive patients in clinical care. AIDS 18(16): 2185-2189, 2004.

Martin JI. Loneliness and sexual risk behavior in gay men. Psychol Rep. 81(3 Pt 1): 815-825, 1997.

Miller M. A model to explain the relationship between sexual abuse and HIV risk among women. AIDS Care. 11(1): 3-20, 1999.

Petrak J et al. The association between abuse in childhood and STD/HIV risk behaviours in female genitourinary (GU) clinic attendees. Sex Transm Infect. 76(6): 457-461, 2000.

Rogers G. Depressive disorders and unprotected casual anal sex among Australian homosexually active men in primary care. HIV Medicine 4, 271–275, 2003.

Ross MW. Measurement and correlates of internalized homophobia: a factor analytic study. J Clin Psychol. 52(1): 15-21, 1996.