Gay men who are HIV-positive or who put themselves at risk of HIV infection through their sexual behaviour are likely to have multiple other social and psychological concerns, according to US research published in the May 2003 edition of the American Journal of Public Health. The study also found that there is an “additive interplay” between these concerns that increases a gay man’s vulnerability to HIV.
Earlier studies have established a link between a history of recreational drug taking, depression, abusive relations, and childhood abuse and an increased risk of a gay man becoming HIV-positive. Investigators at the US Centers for Disease Control wished to see if these problems acted in synergy and if having a history of one social or psychological condition increased the chances of having others, and if this was driving the US HIV epidemic amongst gay men.
The study involved 2881 men aged over 18 who identified as gay or had had sex with another man since the age of 14. The men were recruited in Chicago, Los Angeles, New York and San Francisco, US cities with large and well-established populations of gay men. Interviews were conducted over the telephone, lasting an average of 75 minutes.
Demographic information was obtained, including age, level of education, income, race and HIV status, which was confirmed in a subsample using an oral HIV test. High risk HIV risk behaviour was defined as unprotected anal sex with a man of a different or unknown HIV status.
Four psychosocial problems were also measured. These were: the use of three or more recreational drugs; a history of major depression; partner violence; and, childhood sexual abuse.
Using the results, the investigators created two models. The first looked that the characteristics of men reporting each of the four psychosocial problems. The second tested whether these health problems were additive.
The investigators established that each of the health problems was independently associated with the others. In addition drug use (OR=2.2; 95% CI=1.7-2.8), partner violence (OR=1.5; 95% CI=1.2-1.9) were significantly associated with being HIV-positive, and depression (OR=1.2; 95% CI = 0.9 – 1.9) and childhood sexual abuse (0R 1.1; 95% CI = 0.9 – 1.5) had associations, but these were not significant. In addition, drug use (OR=2.0; 95% CI=1.5 – 2.7), partner violence (OR = 1.7; 95% CI=1.3 – 2.3) and childhood sexual abuse (OR=1.4; 95% CI=1.1 – 1.9) were significantly associated with high-risk sexual behaviour. Although an association was found with depression, this was not significant (OR=1.1; 95% CI=0.8-1.5). After adjusting for demographic variables these associations remained significant (OR=1.7; 95% CI=1.2 – 2.3).
In addition, the investigators found that having greater numbers of health problems was “positively and significantly associated with HIV infection and current high risk sexual practices.” The greater the number of psychosocial problems, the greater the odds ratio of being HIV-positive. One problem OR=1.8; 95% CI=1.4-2.3, two problems OR=2.7; 95% CI 2.0=3.6, three and four problems OR=2.2; 95% CI=1.4 – 3.5; p=<.001.>
This association was also found for high risk sexual activity.
The investigators note that their study extends the literature on the association between other health problems and HIV risk “to show that the connection between these…health problems and HIV/AIDS is far more complex than a 1-to-1 relationship; rather it is the additional interplay of these health problems that magnifies the vulnerability of a population to serious health conditions such as HIV.”
They suggest that this interplay could also be present for other urban populations at high risk of HIV including intravenous drug users and heterosexuals with high-risk behaviour.
”Men who are mired in the combined effects of depression, substance abuse, and violence may not have the capacity to reduce their sexual risk” suggest the investigators, concluding that “the lifelong effects of social marginalization or stigma may work to create high occurrence of psychological health problems among urban M(en who have) S(ex with) M(en), problems that in turn function in an additive manner to raise levels of high-risk sexual behavior and thus HIV infection itself.”
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Stall R et al. Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. American Journal of Public Health 93: 939 – 942, 2003.