How Does Mental Health Affect HIV Prevention?

What does mental health have to do with HIV prevention?

As much as the HIV epidemic has changed over the past 20 years, most reasons for continued high-risk sexual behavior have remained very much the same. Some factors that contribute to these behaviors are: loneliness, depression, low self-esteem, sexual compulsivity, sexual abuse, marginalization, lack of power and oppression. These issues do not have quick fixes. Addressing these basic issues requires time and effort and may extend beyond the capabilities of most HIV prevention programs.

One thing we have learned from HIV prevention research is that "one size does not fit all." Programs need different components to address the different needs of clients. Increasing knowledge, skills building and increasing access to condoms and syringes are good methods but don't work for everyone or on their own. For many, the barriers to behavior change are mental health problems. This fact sheet focuses on non-acute mental health issues and does not address the effect of severe mental illness or brain disorders on HIV prevention.

What people do and what they experience affects their mental health. Substance use and abuse, discrimination, marginalization and poverty are all factors that impact mental health and, in turn, can place people at risk for HIV infection.

Do mental health issues affect HIV risk?

Yes. The decision to engage in risky sexual or drug-using practices may not always be a consciously made "decision." Rather, it is based on an attempt to satisfy some other need, for example:

LOW SELF-ESTEEM. For many men who have sex with men (MSM), low self-esteem and internalized homophobia can impact HIV risk-taking. Internalized homophobia is a sense of unhappiness, lack of self-acceptance or self-condemnation of being gay. In one study, men who experienced internalized homophobia were more likely to be HIV+, had less relationship satisfaction and spent less social time with gay people. 1

Male-to-female transgender persons (MTFs) identify low self-esteem, depression, feelings of isolation, rejection and powerlessness as barriers to HIV risk reduction. For example, many MTFs state that they engage in unprotected sex because it validates their female gender identity and boosts their self-esteem. 2

ANXIETY AND DEPRESSION. Young adults who suffer from anxiety and depression are much more likely to engage in high-risk activities such as prostitution, both injection and non-injection drug use and choosing high-risk partners. One study that followed inner-city youths for several years found that change in risk behavior was not associated with knowledge, access to information, counseling or knowing someone with AIDS. Reducing symptoms of depression and other mental health issues were, however, associated with reductions in HIV-related risk behaviors. 3

SEXUAL ABUSE. Persons who experience incidents of sexual abuse during childhood and adolescence are at a significantly higher risk of mental health problems and HIV risk behavior. A study of adult gay and bisexual men found that those who had been abused were much more likely to engage in unprotected anal intercourse and injecting drug use. 4

For many women, sexual abuse is combined with physical and/or emotional abuse in childhood or adolescence. HIV risk is only one of the consequences of this abuse for women. Women may turn to drug use as a way of coping with abuse experience(s). They may also have difficulty adjusting sexually, causing difficulty negotiating condom use with partners and increasing the likelihood of sexual risk-taking. 5 Women who have been abused have higher rates of sexually transmitted diseases (STDs) including HIV. 6

POSTTRAUMATIC STRESS DISORDER (PTSD). PTSD may account for high sexual risk-taking activities. In one study among female crack users in the South Bronx, NY, 59% of women interviewed were diagnosed with PTSD due to violent traumas such as assault, rape or witness to murder, and non-violent traumas such as homelessness, loss of children or serious accident. 7 A national study of veterans found that substance abusers who suffered from PTSD were almost 12 times more likely to be HIV-infected than veterans who were not substance abusers nor suffering from PTSD. 8

What factors impact mental health? Many persons who suffer from mental health problems turn to substance use as a means of coping. Substance use has been shown to decrease inhibitions and impair judgment, which can contribute to HIV risk-taking. Injection drug users (IDUs) who suffer from depression are at higher risk for needle sharing. 9

Environmental factors such as poverty, racism and marginalization can lead to mental health problems such as low self-esteem which can in turn, lead to substance use and other HIV risk behaviors. Inner-city young adults with high rates of HIV risk behaviors also experience higher rates of suicidality, substance misuse, antisocial behavior, stressful events and neighborhood murders. 10

What's being done?

Addressing mental health issues does not only mean getting clients to see an individual counselor or therapist. Community-level and structural programs can also address mental health needs. For example, a program can hire a trained facilitator and offer support groups for survivors of sexual abuse. Open houses or drop-in centers where individuals can meet each other can serve to combat loneliness and depression. Offering mobile vans that deliver syringe exchange as well as clothing or food can reach isolated groups that are at high risk for mental health problems and HIV.

The Bodyworkers Program in New York, NY, provides MSM sex workers with free HIV prevention and mental health counseling, peer counseling and access to medical services. Male body workers, escorts, street hustlers, porn stars, go-go dancers and others cited several mental health issues that are barriers to accessing prevention and medical services. They are: mistrust, shame, isolation, fear of personal relationships, sexual compulsivity, depression, low self-esteem, substance abuse and a history of physical/sexual abuse. 11

The HAPPENS (HIV Adolescent Provider and Peer Education Network for Services) Program in Boston, MA, provides a network of youth-specific care to HIV+, homeless and at-risk youth. The program conducts street outreach, offers individual HIV risk reduction counseling and links youth to appropriate social, medical and mental health services. All health care visits include a mental health intake and mental health services are offered both on a regular basis and at times of crisis. 12

A program in New Haven, CT, used a street-based interactive case management model to reach drug-using women with or at risk for HIV. Case managers traveled in mobile health units to provide intensive one-on-one counseling on-site. Counseling often included discussions among members of the client's family and peers. Case managers also provided transportation, crisis intervention, court accompaniment, family assistance and donated food and clothing. 13

What are the implications for prevention programs?

Persons working in HIV prevention need to be aware of the close association between mental health, social and environmental factors and an individual's ability to make and maintain behavior changes. Prevention program staff should be trained to look for and identify mental health problems in clients. If mental health staff are not available on-site, programs can provide referrals to counselors as needed. Some service agencies have integrated mental health services into their overall services and can provide counseling as part of their prevention interventions.

Mental health issues are often overlooked because of stigma on an institutional and individual level. These issues may vary across communities and by geographic region. Addressing mental health problems is an integral part of health promotion and should be a part of HIV prevention. It is not about labeling or putting people down, but about providing accurate diagnoses and treatments for mental and physical health.

Read: Everything you need to know about AIDS testing

Says who?

1. Ross MW, Rosser BR. Measurement and correlates of internalized homophobia: a factor analytic study. Journal of Clinical Psychology. 1996;52:15-21.

2. Clements-Nolle K, Wilkinson W, Kitano K. HIV Prevention and Health Service Needs of the Transgender Community in San Francisco. in W. Bockting & S Kirk editors: Transgender and HIV: Risks, prevention and care. Binghampton, NY: The Haworth Press, Inc. 2001; in press.

3. Stiffman AR, Dore P, Cunningham RM et al. Person and environment in HIV risk behavior change between adolescence and young adulthood. Health Education Quarterly. 1995;22:211-226.

4. Bartholow BN, Doll LS, Joy D, et al. Emotional, behavioral and HIV risks associated with sexual abuse among adult homosexual and bisexual men. Child Abuse and Neglect. 1994;9:747-761.

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

6. Petrak J, Byrne A, Baker M. The association between abuse in childhood and STD/HIV risk behaviors in female genitourinary (GU) clinic attendees. Sexually Transmitted Infections. 2000;6:457-461.

7. Fullilove MT, Fullilove RE, Smith M, et al. Violence, trauma and post-traumatic stress disorder among women drug users. Journal of Traumatic Stress. 1993;6:533-543.

8. Hoff RA, Beam-Goulet J, Rosenheck RA. Mental disorder as a risk factor for HIV infection in a sample of veterans. Journal of Nervous and Mental Disease. 1997;185:556-560.

9. Mandel W, Kim J, Latkin C, et al. Depressive symptoms, drug network, and their synergistic effect on needle-sharing behavior among street injection drug users. American Journal of Drug and Alcohol Abuse. 1999;25:117-127.

10. Stiffman AR,Doré P, Earls F, et al. The influence of mental health problems on AIDS-related risk behaviors in young adults. Journal of Nervous and Mental Disease. 1992;180:314-320.

11. Baney M, Dalit B, Koegel H et al. Wellness program for MSM sex workers. Presented at the International Conference on AIDS, Durban, South Africa. 2000. Abstract #MoOrD255.

12. Woods ER, Samples CL, Melchiono MW, et al. Boston HAPPENS Program: a model of health care for HIV-positive, homeless and at-risk youth. Journal of Adolescent Health. 1998;23:37-48.

13. Thompson AS, Blankenship KM, Selwyn PA, et al. Evaluation of an innovative program to address the health and social service needs of drug-using women with or at risk for HIV infection. Journal of Community Health. 1998;23:419-421.

Prepared by Jim Dilley, MD, Pamela Decarlo, AIDS Health Project, CAPS, September 2001