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Under The Radar: Mental Health and HIV Risk

November 22, 2011

For our World AIDS Day 2011 section, we wanted to capture the diversity of the HIV community. So, we reached out to people across the world -- regular contributors and those who have never written for us before -- and asked them to guest blog. These columns are written by people who are living with HIV, have been affected by HIV, or work in the field.

David Fawcett, Ph.D., L.C.S.W.

David Fawcett, Ph.D., L.C.S.W.

Getting the level of new infections down to zero will require breakthroughs not only in medications and improved interventions, but also a broadening of our understanding about the underlying causes of high-risk behaviors which can increase vulnerability for HIV, specifically, mental health concerns.

The emotional impact of diagnosis is clearly understood. After all, who wouldn't be depressed upon hearing they have HIV? Can we be surprised that a positive test result can be traumatic? But what about the impact of depression or trauma on the risk of acquiring HIV? Increasingly, we know that depression not only occurs after diagnosis, but actually significantly increases the risk of becoming infected. It is natural that trauma can result from seroconversion, but we now know it is a major risk factor for HIV long before dangerous behavior takes place. The earlier we identify and intervene on these conditions, the better chance we have of reducing the number of new infections.

The following are just a few of the issues I feel should become increasingly integrated into our research and programming.


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Depressive Disorders

Numerous studies have documented the impact of depression on high-risk behaviors such as unprotected sexual intercourse, multiple sex partners, trading sex for money or drugs, and contracting sexually transmitted diseases, yet mental health is rarely a component of the design of HIV prevention and intervention programs. Depression can lead to substance abuse, itself a high-risk behavior, but even when studies control for substance abuse, depression alone remains a significant factor. It leads to a sense of hopelessness and guilt, and severely impacts one's emotional resilience and self-esteem. Depression leads to high-risk behaviors which effectively distract or numb an individual from symptoms, but also greatly increase the risk of acquiring HIV or other sexually transmitted infections.


Sensation Seeking

Defined as the need for thrilling, adventuresome, novel, and often dangerous experiences, sensation seeking is increasingly being identified as a separate phenomenon which can increase HIV risk. Sensation seeking can, of course, lead to substance abuse, but it can independently impact sexual behaviors (multiple partners, risky sex). Men and women who seek increased stimulation appear to have a low tolerance for boredom, and contrary to common assumption, sexual compulsivity is not impulsive or pleasure-directed, but is associated with lower levels of self-esteem. I have had clients, for example, who "act out" sexually not for pleasure but to manage emotional pain. They seek to numb painful feelings by repeatedly having risky sex, and despite numerous sexual encounters, they end up feeling sad and "empty."


Childhood Sexual Abuse

Such abuse has been in the news recently and the statistics are truly shocking. Prevalence studies of adults estimate that between 6 and 62 percent of women and 3 to 31 percent of men were sexually abused before the age of 18. Many experts believe these numbers may actually be low. Clearly, such a childhood experience is devastating both at that time and in later life. The effects of trauma can lead to increased rates of addiction, sexual dysfunction, depression, post-traumatic stress disorder, and other significant concerns. But what about risk for HIV?

Childhood victims have a higher risk of becoming infected because of the long-lasting impact of abuse. Such men and women are significantly more likely to become involved in sex work, to change sexual partners frequently, and to engage in sex with casual acquaintances. They use larger quantities of addictive substances, and use them more frequently, and experience a disruption in the development of appropriate sexual behaviors. Cleary, safer sex messages alone are largely ineffective for individuals whose lives have been disrupted by sexual assault.


Intimate Partner Violence

Research has begun to document a correlation between risk of HIV and intimate partner violence (IPV). Although both sexes can be vulnerable, the majority of persons experiencing IPV are female. Possible mechanisms of increased risk include the consequences of forced sex and injury to the mucous membrane as well as an impeded ability to negotiate safe sex behaviors such as negotiating condom use or refusing sex. IPV can predispose an individual to engage in sexually risky behaviors which in turn increase the risk of HIV infection. A history of IPV can also negatively impact one's willingness to engage in voluntary HIV testing due to shame, stigma, or fear. Once infected, a history of IPV, which is known to have immunosuppressive effects, can lead to a faster progression of the disease. There are very few programs that address HIV and intimate partner violence risk reduction simultaneously, making this an area needing urgent attention.


Redefining the Epidemic

To be truly effective, HIV prevention and intervention programs must broaden their scope to include a variety of other issues that directly impact the risk of acquiring HIV. "Syndemics," or simultaneous epidemics, is a useful approach that more realistically reflects what I see in my office and in the community. There are issues of HIV, other sexually transmitted infections, mental health disorders, addictions, trauma, and maladaptive behaviors such as sensation seeking that increase an individual's risk. The HIV community, largely due to accidents of history, is divided by funding streams and professional training into separate silos that too often lack an integrated understanding of what any one individual is or has experienced that could put him/her at increased risk.

We need to be certain our outreach and prevention efforts incorporate the effects of mood disorders and behavioral concerns on sexual behaviors. We need to understand that all sexual behavior is not the result of free will but may, in fact, be driven by coercion or survival. We need to understand that high-risk sexual behavior or addictions may result from a history of childhood sexual abuse and integrate this information into our interventions. To truly get to zero, we need to broaden our reach to all of the varied settings where vulnerability for HIV is born.

David Fawcett, Ph.D., L.C.S.W., is a substance abuse expert, certified sex therapist and clinical hypnotherapist in private practice in Ft. Lauderdale, Fla.

Read more of Riding the Tiger: Life Lessons From an HIV-Positive Therapist, David's blog, on TheBody.com.


Copyright © 2011 The HealthCentral Network, Inc. All rights reserved.

This article was provided by TheBody.com.
 
See Also
Guide to Conquering the Fear, Shame and Anxiety of HIV
Trauma: Frozen Moments, Frozen Lives
More on Coping With Mental Health Issues

Reader Comments:

Comment by: John Eisenhans (St. Louis, MO) Tue., Dec. 6, 2011 at 8:21 am EST
Great article; thank you for writing it, David. What I can't comprehend (or forgive) is that I haven't read thousands like it and beyond, and that the folks in the "public health/prevention" silo haven't read any. Apparently the concepts you expound have never crossed their collective mind. Either that or they are doing their best to perpetuate both epidemics - of depression and of HIV.

Don's contribution here is important and so hard to read. My own experience is similar, but I have been far more fortunate. Nevertheless the damage is done. I am grateful to have an excellent therapist who is very well aware of the impacts of depression, PTSD, "thrill seeking," etc. as well as the direct impacts of HIV. Along with my physician and my partner, my therapist has helped me find a life worth living, despite having to share it with this godawful virus. I wish the same for Don and for all of us in this boat.

For those in public health or HIV prevention, please consider a strategy that takes David's observations into account. Shaming, threatening, stigmatizing and sermonizing are not working. They never have and never will. If that's really all you have to offer, please find another line of work.
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Comment by: Don (Los Angeles, CA) Thu., Dec. 1, 2011 at 3:07 am EST
I'd thought further any danger had ended when AIDS was somewhat brought under control in the 1990s. I was already a long-term HIV+ survivor, had lost scores and scores of dear ones (in fact every single Gay man I knew or had known to that point) so figured what's more to lose? Your article indicates that I'm still affected strongly by at least two of the issues you describe, and I am realizing I'm still not free from others that cause pain, confusion, horrendous discomfort in other areas. Yes, I was subjected to sexual abuse until the age of about 14. Yes, I've determined that, being HIV+, what more do I have to lose by indulging in "raw" sexual encounters with other poz men? But since a relative of mine recently was put on disability after one difficult but singular experience at work, I've studied, followed up on observations of acquaintances, and realize that I, too, suffer from Post Traumatic Stress Disorder after becoming HIV+ before the epidemic had even been discovered (1978) and spending nearly 20 yrs expecting death any week, attending 3-4 "memorial services" on weekends, watching society flow past undisturbed while my friends were dying in droves (at least 30 while I was in attendance at their bedside or in physical contact with their bodies as they took leave) and never once having family or straight friends ask how I was handling it, how I was doing, what they could do to help me buck up. I'm a wreck. My M.D. says I could live into my 80s or more with current treatments, but under these conditions I'm not sure I wish to. Nightmares, depression, isolation. I'm in L.A., have been on SSDI for yrs, have no car and less than $200 savings. No way could I seek therapy. What to do? Yes, barebacking isn't the answer but it's the only pleasure that distracts me from the godawful memories of that time, or from the rage I feel toward all who Fate chose to let it pass by without their notice or regard. Any suggestions? Please?
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Replies to this comment:
Comment by: David Fawcett (Fort Lauderdale, FL) Sun., Dec. 4, 2011 at 2:57 pm EST
Thank you for writing. There are many of us who experienced our own holocaust (I don't use the world lightly) during the 1980s and beyond and still have a deep well of unexpressed grief, made worse in that it has been largely unrecognized or nearly forgotten. In that article I wrote about the role of trauma, both as a precursor to HIV/AIDS and as a consequence of diagnosis. Trauma and post traumatic stress disorder don't resolve on their own. There are effective treatments such as psychotherapy (including types of hypnotherapy and EMDR) and support groups. Left untreated, trauma can lead to efforts to numb the painful feelings, including addictions and compulsive behaviors.

You don't have to remain stuck in painful memories or rage. I encourage you to contact a local HIV service agency (AIDS Project Los Angeles, which has a very comprehensive variety of services, is the largest near you). They may be able to connect you with treatment options that could really help.

Good luck.

-David


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