This article was originally posted on TheBody.com on David's blog "Riding the Tiger: Life Lessons from an HIV-positive Therapist"
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.
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.
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 to 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.