A UK study of HIV patients at four clinics in London and one in Brighton has found that 31% reported having had suicidal thoughts over the previous week.
The study, published in the journal AIDS , found that heterosexual men, people of black ethnicity and people who had not disclosed their status to anyone were about twice as likely to have suicidal thoughts as other groups.
Other strong predictors of suicidal ideation were being unemployed, being single, and having stopped HIV treatment, though these factors lost significance in multivariate analysis.
Suicidal thoughts were also associated with poor treatment adherence and with having poorer physical and/or mental health, but were not associated with age, being on treatment, time on treatment, type of treatment or viral load.
Since 1990, the authors note, 271 or nearly 2% of the approximately 14,000 HIV positive people who have died in the UK have taken their own lives, and the proportion of deaths due to suicide has increased in the period since effective HIV treatment became available. However, there have not been many studies of suicidality since the advent of combination HIV treatment, and studies have also left it unclear as to whether HIV infection was independently associated with suicidal thoughts or whether they were simply more common in the kinds of people more vulnerable to HIV.
The UK study, led by Professor Lorraine Sherr of Royal Free and University College Medical School, asked all 903 eligible patients attending the five clinics in a three-month period in 2005 and 2006 to fill in a confidential questionnaire asking then whether they had experienced suicidal thoughts over the previous week, and if so how frequently.
It also established demographic information and asked about sexual behaviour and relationship status, treatment optimism and whether patients had disclosed their HIV status to anyone, treatment status and adherence to treatment, symptoms of physical and mental ill-health, and general quality of life. There was a high response rate, with 86% of eligible patients filling in the questionnaire.
Two-thirds of the patient group were gay men, a quarter women, and 10% heterosexual men. Just over half had been born in the UK; 25% described themselves as black and 8% Asian or other, with the remainder describing themselves as white. Twenty-one per cent had never taken antiretroviral therapy, 66% were currently taking such treatment and 13% had anti-HIV drugs but had stopped. Fifty-three per cent were employed.
Of the 31% who had had suicidal thoughts over the last week, just over 10% said the thoughts were “frequent” and just over 5% ‘constant’. The rest said they were occasional.
The raw data show that the strongest predictors of suicidality were, in this order, being in poor physical or mental heath; being unemployed; being poorly adherent; not being in a stable relationship; not having disclosed HIV status to anyone outside the clinic; being of black ethnicity; and being a heterosexual man. Interestingly, there was no association between NNRTI use and suicidal ideation despite the most widely prescribed NNRTI being efavirenz (Sustiva), which has been associated with depression and suicide in other studies.
Factors not associated with suicide included age, having had unsafe sex, number of sex partners, pessimism about treatment or being infectious, and type of treatment. However suicidality was significantly higher in those who had stopped treatment (43%), and there was the same rate of suicidal ideation in those who were poorly adherent.
After multivariate analysis, sexuality, ethnicity, disclosure and state of physical and mental health remained the only independent predictors of suicidality. Heterosexual men nearly twice as likely as gay men and 2.5 times more likely than women to feel suicidal; black people nearly twice as likely as white (most heterosexual men were black); and people in poor mental health, unsurprisingly, 2.3 times more likely. The association between suicidality and being a heterosexual man was even stronger in the patients on HIV treatment.
The present study appears to back the idea that HIV infection is an independent psychological stressor in its own right. The authors point out that the 31% rate of suicidal thinking is more than twice as high as that observed in gay men (13%), a group known for high suicide rates. And the fact that 45% of heterosexual men recorded suicidal thinking in the present study, as opposed to 30% of gay men, would point to HIV infection and related factors such as stigma and shame, poor health and health pessimism, and what the authors call “the burden of secrecy and lack of community and social support” as being the most significant influences on suicidal thinking.
Sherr L et al. Suicidal ideation in UK HIV clinic attenders. AIDS 22(13):1651-1658. 2008.