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Keywords:

  • homosexual men;
  • neuropsychological;
  • prevention of sexual transmission;
  • psychiatry;
  • psychosocial;
  • risk factors;
  • sexual behaviour

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Objective

To examine the relationship between depressive disorders and unprotected anal intercourse with casual partners, among homosexually active men attending for primary care.

Methods

The first 460 homosexually active men enrolling in an Australian integrated primary care programme were screened for current depressive disorders using the Primary Care Evaluation of Mental Disorders (PRIME-MD) and completed questionnaires on their sexual behaviour in the prior 6 months. One hundred and sixty-two (35%) were HIV positive, 283 (62%) were HIV negative and 15 (3%) were untested.

Results

The prevalence of major depressive episode (MDE), as measured by the PRIME-MD, on enrolment was 28% (129/460), while the prevalence of dysthymic disorder (DD) was 26% (121/460). These include 84 men (18%) who met the criteria for both disorders (‘double depression’). Neither disorder was associated with HIV status. Men with MDE were less likely to have been sexually active than the remainder of the cohort (90/129 [70%] vs. 291/331 [88%]; OR: 0.32 [95% CI: 0.19–0.52]; P<0.0001). Men with DD alone, however, were significantly more likely than men with neither disorder to report having had unprotected anal intercourse with a casual partner (11/38 [29%] vs. 43/292 [15%]; OR: 2.36 [95%CI: 1.09–5.10]; P=0.035).

Conclusions

Depressive disorders were highly prevalent in this cohort and independent of HIV status. MDE was associated with reduced sexual activity. Among men without MDE, the presence of DD was independently associated with an increased likelihood of reporting unsafe anal sex with a casual partner in the prior 6 months.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Depressive disorders are highly prevalent in people with HIV infection [1–5]. Clinical wisdom is that this high pre-valence results from the psychosocial stress of HIV diagnosis and disease together, perhaps, with direct neurochemical effects of the virus. A number of studies, however, identify levels of depressive disorder among uninfected members of the communities particularly affected by HIV that are similarly high [6–10]. Ciesla and Roberts, in a recent meta-analysis of 10 studies, concluded that HIV infection did appear to be an independent risk factor for major depression, but not for dysthymic disorder (DD) [11].

The relationship between depression and HIV risk behaviour among gay men has been addressed in many studies, but the results have been conflicting. Ross [12], Kelly [13], Rotherham-Borus [14], Semple [15], Strathdee [16], and Perkins [17], all found that sexual risk taking was associated with the presence of depressive symptoms in a variety of groups of homosexually active men.

Wagner and colleagues, on the other hand, found low levels of sexual activity and sexual risk taking among HIV positive gay men seeking treatment for depression [18]. Dilley found no association between depression scores and sexual risk taking in a group of homosexually active men attending support groups [19], and, while Mayne found that recently bereaved gay men were more likely to engage in unsafe sexual practice, depression did not appear to be significantly related to this behaviour [20].

Dolezal in a recent study of homosexually active Latino men found a positive association between measures of self-worth and sexual risk taking [21], and Robins [22, 23] found that gay men who reported unprotected anal intercourse had lower levels of psychological distress than their peers. Similarly, Rubb's group found that homosexually active men whose responses indicated depressed ideation were less likely to report having engaged in receptive or insertive unprotected anal intercourse [24].

While these results appear conflicting, it seems that no previous study has differentiated between the two common patterns of depression seen clinically, namely major depressive episode (MDE) and DD, for their effect on sexual behaviour.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The South Australian Primary & Extended HIV and Related Diseases Care & Prevention Programme (known as The Care & Prevention Programme) is a government-funded project that aims to assist people with HIV, and people who may be at increased risk of HIV, to maximize their health across the biopsychosocial spectrum. It is situated in the city of Adelaide and has a particular focus on gay and other homosexually active men, who are the group at greatest risk for HIV in Australia.

Participants are referred to the programme by their general practitioners, on the basis of the identification of HIV infection, or membership of a recognized risk group, during routine care. All homosexually active men are encouraged to enrol irrespective of their current state of health or their own pattern of risk behaviour.

Enrolment data are presented here for the first 460 homosexually active men, who enrolled in the programme between 1998 and 2001. The majority of participants were recruited from a group general practice with a special interest in the care of homosexually active men. Although formal participation records were not kept, very few referred subjects declined to participate.

The programme's protocols have been approved by the University of Adelaide Human Research Ethics Committee.

All participants undergo extensive biopsychosocial health assessment by the programme's registered nurse on enrolment and periodically thereafter. Assessment includes assisted self-administration of a computerized version of the Primary Care Evaluation of Mental Disorders (PRIME-MD), which seeks to identify common psychiatric diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria.

The instrument detects two principal depressive conditions: MDE and DD. Under the DSM-IV, an MDE is the experience, for a period of at least 2 weeks, of significantly depressed mood, or reduced interest or pleasure, accompanied by a minimum of four other specified symptoms. DD is a less intense, but chronic form of depression that is diagnosed when a person has experienced depressed mood for the majority of time over 2 years. Both conditions can be diagnosed together where an MDE supervenes on a DD background (so-called ‘double depression’). Any of these diagnoses require that the disturbance has significantly impaired the subject's functioning while it has been present.

The recent sexual behaviour of enrolees is also assessed by self-report according to a protocol modified from that developed by the (Australian) National Centre for HIV Epidemiology and Clinical Research for the Sydney Men and Sexual Health Study [25]. Further questionnaires identify medical history, recreational and prescription drug use patterns, quality-of-life and the HIV-specific health characteristics of positive participants.

For this analysis, the presence or absence of PRIME-MD diagnoses and sexual behaviours were compared using two by two tables to calculate odds ratios (OR), 95% confidence intervals (95%CI) and Fisher's exact test of significance was employed. The multivariate analysis was undertaken using binary logistic regression.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Of 460 homosexually active men, 162 (35%) were HIV positive, 283 (62%) were HIV negative and 15 (3%) had not been tested. Their median age was 39 years and the HIV-positive men were significantly younger (median 38) than the HIV-negative men (median 41, P=0.029). Eighty-three per cent were born in Australia and almost all were Caucasian; 40% lived alone; and 53% were employed or self-employed either full or part time, HIV positive men were less likely to have employment (36%) than HIV negative (65%, P<0.0001). Both groups were significantly less likely to be employed than adult men in the South Australian community generally (80% employed, P<0.0001 for difference from either group) [26]. HIV-positive men had median incomes markedly below, and HIV-negative men slightly below, the average for South Australians. Among the positive men, 118 (73%) were taking antiviral therapy at enrolment. Twenty-one (13%) were on nucleoside reverse transcriptase-inhibitor (NRTI)-only regimens, 52 (32%) on protease inhibitor (PI) regimens without a non-nucleoside reverse transcriptase inhibitor (NNRTI), 31 (19%) on NNRTI regimens without a PI, and 14 (9%) on regimens containing all three therapeutic classes. No associations were seen between therapy use or class and any of the other variables described in this paper.

Sixty-six of the 460 men (14%) reported unprotected anal sex with a casual partner (either as inserter, receiver, or both) on at least one occasion in the 6 months prior to assessment. Thirty of 162 HIV-positive men (19%) reported the activity compared with 34 of 283 HIV-negative men (12%; OR: 1.66; 95% CI: 0.97–2.84; P=0.068).

One hundred and twenty-nine men (28%) met the criteria for a current major depressive episode on enrolment into the programme. One hundred and twenty-one (26%) had diagnosable DD. This prevalence includes 84 men (18% of the cohort) who met the criteria for both disorders (‘double depression’).

The prevalence of major depression was the same in HIV-positive (45/162, 28%) and HIV-negative (79/283, 28%) participants. Similarly, there was no difference in prevalence for DD in HIV-positive men (43/162, 27%) compared with HIV-negative men (75/283, 27%).

On initial analysis of the whole cohort, no significant association was seen between DD and the likelihood of reporting unprotected anal sex with a casual partner in the 6 months prior to assessment (OR for unprotected casual anal sex by DD men was 1.49, 95%CI: 0.85–2.61, NS).

One of the symptoms of major depression, however, is reduced libido. Consequently, it is no surprise that men with this diagnosis were less likely to have been homosexually active at all during the period in question (OR for sex with males by depressed men was 0.32 (95%CI: 0.19–0.52, P<0.0001). Since a major depressive episode may supervene in a person who also continues to meet the criteria for DD, this effect could confound any association between DD and unsafe sexual behaviour.

To investigate this, we excluded the 129 men with current major depression and examined the relationship between DD in the absence of major depression and the likelihood of reporting unprotected anal intercourse with a casual partner in the prior 6 months. As can be seen from Table 1, homosexually active men with long-term, low-grade depression that was not currently complicated by a more acute episode, were significantly more likely to report having engaged in unprotected anal sexual activity with a casual partner (OR: 2.36; 95%CI: 1.09–5.10; P=0.035).

Table 1.   Unprotected anal intercourse (UAI) with a casual partner in prior six months by presence of dysthymic disorder in 331 homosexually active men without major depression
 Unprotected anal sexNo unprotected anal sexTotal
Dysthymic disorder11 (29%)27 (71%)38
No dysthymic disorder43 (15%)250 (85%)293
Total54 (16%)276 (84%)331

Among these men, report of unprotected anal intercourse with a casual partner was also significantly associated, univariately, with HIV positivity, excessive alcohol use, current nitrite use, current amphetamine use and current injecting use of any drug. In a multivariate model incorporating these variables, DD (OR=2.32, 95%CI: 1.02–5.24, P=0.044), current nitrite use (OR=2.24, 95%CI: 1.21–4.16, P=0.010) and current injecting use of any drug (OR=3.76, 95%CI: 1.14–12.48, P=0.030) remained significantly associated with the risk behaviour.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Depressive disorders were highly prevalent among homosexually active men enrolling in the programme. HIV-positive men did not differ in their prevalence of either depressive disorder from HIV-negative homosexually active men in the cohort and so, perhaps surprisingly, HIV infection does not appear to be a significant determinant of depression in this cohort.

The prevalence of major depression was more than eight times the annual prevalence of the condition (as measured by the Composite International Diagnostic Interview [CIDI]) in South Australian adult males in the National Mental Health Survey [27].

It should be remembered that this is a clinical cohort and so a higher prevalence of depression would be expected in comparison to community surveys. It is of interest, however, that in the original validation study for the PRIME-MD, the prevalence of major depression was only 6% in adult male attenders at four primary care clinics in the USA, compared with 28% in the Care & Prevention Programme cohort [28]. No comparable general practice clinical prevalence studies appear to have been done, to date, in Australia, but in a 1991 study, the prevalence of major depression (by an earlier version of the PRIME-MD using DSM IIIR criteria) among hospital in-patients was 12%, or less than half the rate in the cohort [29].

With regard to DD, the prevalence in the cohort was 14 times the rate measured with the CIDI among South Australian adult men in the National Mental Health Survey. In a recent study from a Canadian primary health care unit, the prevalence of DD in adult male attenders (as measured by the CIDI) was 3.9% [30]. The rate of DD in the programme cohort (as measured by the PRIME-MD) is more than six times this rate.

In the literature, the only head-to-head comparison between the CIDI and the PRIME-MD (in its German version) was undertaken by Loerch and colleagues [31]. Their study suggests that the CIDI is more sensitive than the PRIME-MD for both MDE and DD, and that the PRIME-MD has an excellent negative predictive value for both conditions (that is, it is most unlikely to falsely diagnose a respondent positive). These characteristics would be expected to minimize, rather than magnify, the apparent differences in prevalence we have observed and so lend support to our conclusions that homosexually active men in this cohort were, indeed, more likely to be depressed or dysthymic than either men in the general South Australian community or the clinical groups assessed with the CIDI by other workers.

The results of our study suggest that the apparently conflicting evidence in the literature with regard to the effects of depression on sexual behaviour may be explained by a difference in the effect of the two common patterns of depression. This differentiation does not appear to have been reported previously. We have identified DD without current major depression as a significant independent risk factor, in this cohort of homosexually active men, for sexual behaviour that may increase the likelihood of HIV transmission.

The results of this study are limited by its cross-sectional nature and by the instruments used to identify the presence of depressive disorders and to measure sexual behaviour. The PRIME-MD has been demonstrated to be valid and reproducible as a screen for depressive disorders in primary care samples in the USA, but has not been formally validated in Australia or among samples of homosexually active men. Despite their general validity, measures of sexual behaviour rely on retrospective self-reporting. It is unclear whether men with and without DD would differ in their vulnerability to over- or under-reporting by these measures.

The generalizability of the results is also limited by the fact that participants were sampled only from homosexually active men who were already engaged with primary care clinical services. It is well understood that a significant proportion of men with depressive disorders do not present for clinical care. This study provides no information about the influence of DD on sexual behaviour among homosexually active men in this group.

In addition, individual characteristics and disorders of personality, described along Axis II of the DSM-IV, might also have a significant influence on sexual behaviour among homosexually active men. This was not explored in our investigation, and has been little studied by other authors, most likely due to difficulty with the comprehensive measurement of these characteristics in a valid and reliable fashion.

Despite success in HIV prevention by educational means in Australia, the rate of new infections now appears to have reached a plateau, with the suggestion of a rise in some regions. The clear majority of ongoing transmission occurs between homosexually active men [32]. Most gay men in Australia are now well informed about the mechanisms of HIV transmission and further prevention efforts will need to focus on factors that influence the ability of individuals to translate knowledge into protective behaviour. When the confounding effects of major depression are set aside, the low-grade, long-term depression of DD may be one such factor.

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. DD may be the diagnostic representation of such a mental state and since the condition may be amenable to psychotherapeutic or pharmacological intervention [33], it warrants careful consideration in the prevention of HIV at individual and population levels.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The first 2 years of this study were undertaken under the auspices of Adelaide Central and Eastern Division of General Practice. The programme was funded by the Commonwealth Department of Health and Ageing, and the South Australian Department of Human Services. Small, unrestricted grants were received from Merck Sharp and Dohme, GlaxoSmithKline, Bristol-Myers Squibb, Abbott Australasia, Roche Products, Pharmacia and Upjohn, and Pfizer.

Early results of this work were presented at the Twelfth Annual Conference of the Australasian Society for HIV Medicine, Melbourne, 2000 [abstract 85].

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  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
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