Abstract
In Australia, the predominate mode of transmission for HIV infection has been same-sex intercourse between males [1]. More than 85% of HIV transmissions are estimated to have occurred via male homosexual/bisexual sexual contact [1]. The preponderance of gay men among people who are HIV positive has resulted in the relative neglect of other subgroups who may be at high risk of HIV, such as the chronic mentally ill [2].
Although numerous studies [3–6] have found that the prevalence of HIV is much higher among people with chronic mental illness than among the general population, other studies have found that HIV risk among mentally ill patients is often neglected by mental health practitioners [7]. Thompson et al. [7] found high rates of risk behaviour among psychiatric patients yet only 16% of patients had ever had anyone talk to them specifically about HIV and its transmission.
The majority of prevalence studies of HIV in psychiatric populations have emanated from the USA, and have estimated an HIV seroprevalence ranging from 4% to 23% [4]. Prevalence data from other countries, including Australia, are limited. However, one Australian report has estimated a HIV seroprevalence of 1–5% for people attending the Sydney Inner City Mental Health Service [8]. In contrast, the seroprevalence rate for the Australian community is less than 0.1%.
The higher risk for HIV transmission among the mentally ill is due to a combination of psychiatric symptoms leading to risk behaviours and associated problems of substance abuse, as well as social and interpersonal difficulties. For example, in patients with bipolar mood disorder, mania may lead to increased sexual drive and increased high-risk behaviours. People with depression often have poor self-care, while individuals with chronic schizophrenia may have poor planning and poor judgement.
The study by Thompson et al. [7] documented the prevalence of risk factors for HIV infection among people with chronic mental illness in an Australian setting. They found that people with mental illness were more likely than the general population to have a history of injecting drug use (IDU) and to report having sex with a prostitute in the past year. Almost 10% of men with mental illness had had anal sex with another man and 19% of women had had sex with a bisexual man. The mentally ill were also highly likely to have had multiple sexual partners in the past year. High rates of injecting drug use (IDU) among people with mental illness also puts them at risk of infection with the hepatitis C virus (HCV). The HCV has become the most commonly reported notifiable infection in Australia [1] and has serious physical health consequences.
People with psychiatric disorders who are infected with HIV account for a disproportionate amount of time and resources in case management, welfare and support services. Yet, to our knowledge, the study by Thompson et al. is the only published Australian study on this subject.
The current study was designed to extend the work of Thompson et al. [7] and document the prevalence of sexual behaviour and drug-taking practices that are known risk factors for the transmission of HIV and HCV among people attending community mental health services.
Method
The methods used in this study have been described elsewhere [9]. Briefly, 234 outpatients of four Area Mental Health Services in the North-western Health Care Network Mental Health Program were interviewed about their health behaviour and underwent a brief physical examination. Participants were asked about a range of health behaviours including those related to preventive service use and cardiovascular risk [9]. This paper will report the results related to risk of HIV and HCV.
A 10-item measure of sexual behaviour was adapted from the scale developed by Volavka et al. [10]. The scale included items on the number of sexual partners in the past 12 months, the incidence of homosexual sex, sex with high-risk partners and use of condoms during sex. Additional items on this measure distinguished between condom use with casual partners and regular partners.
Information on illicit drug use was obtained using a seven-item instrument adapted from the 1995 National Drug Strategy Household Survey [11]. This measure examines the use of a range of illicit drugs over the previous 12-month period and includes items on injecting drug use and sharing needles.
Only patients judged by clinic staff to be capable of giving informed consent were approached for interview. The majority of participants were recruited into the study via their case manager or they were approached at the clinic by the researcher who explained the aims and requirements of the study. A small number of participants were recruited when they contacted the researcher after seeing notices in the clinic advertising the project. Patients were excluded from participation if they were judged by their case manager to be too unwell; were unable to understand the concept of informed consent; were unable to speak English and an interpreter was not available; or were unwilling to participate.
Patients who provided their informed consent to participate in the study were interviewed in a private room at the clinic where they received mental health services. Confidentiality was assured and patient responses were only identified by a number code. Approval for the study was obtained from the Research and Ethics Committee of the North-western Health Care Network.
Analysis
Data were entered into SPSS (SPSS, Chicago, IL, USA) and descriptive analysis was conducted. Odds ratios and confidence intervals (95% CI) were calculated to estimate the differences in the prevalence of risk factors between people with mental illness and the general Australian population. Data on sexual risk factors among people with mental illness were compared, where possible, with data from an Australian populationbased study of the prevalence of HIV risk behaviours conducted by Ross [12]. Data on illicit drug use among the mentally ill was compared with data on the general population provided by the most recent Drug Strategy Household Survey, released in 1999 [11]. Five participants under 20 years of age in the current study were excluded from analysis as they did not constitute a large enough group to compare with the under-20 sample from the National Drug Survey [11].
Results
Sample
The study sample consisted of 97 women and 132 men (n = 229) between the ages of 20–65 years who were living with chronic mental illness. The majority (79%) of the sample had a primary diagnosis of psychotic disorder, followed by major depressive disorder (9%), bipolar disorder (4%), personality disorder (4%), and other disorders (3%). More than half (51%) had been hospitalized for psychiatric illness in the last 12 months, and a further 17% had been hospitalized in the past 3 years. Twenty per cent of the sample were married or living in a de facto relationship at the time of interview and just over half (51%) lived with either their parents or partner and/or children. Few participants were currently employed and 92% received a government pension as their main form of income. Just over one-quarter (27%) were born in a non-English-speaking country.
Sexual behaviour
Forty-three per cent of mentally ill men reported being sexually active in the 12 months prior to the study (Table 1). In contrast, 72% of men in the study by Ross [12] reported that they had heterosexual sex in the previous 12 months. Just over half (51%) of the women in the mentally ill sample reported that they had been sexually active compared with 73% of women who reported they had had sex with a male in the community sample. Ross [12] did not provide overall prevalence rates on people who were sexually active, but divided the data into four categories based on the participants’ gender and the gender of their sexual partner. Therefore, respondents who had sex with both men and women will be recorded twice in Ross's tables [12]. Because the rates of homosexual sex are much lower than the rates of heterosexual sex we have used Ross's figures to provide an estimation (albeit an underestimation because they exclude people who only had sex with same-sex partners) of the prevalence of sexual activity in the general population.
Sexual behaviour in psychiatric outpatients
Among the mentally ill, 19% of men and 43% of women reported being sexually active within a primary relationship, while 29% of men and 14% of women reported being sexually active with casual partners in the last 12 months. Five per cent of men and six per cent of women had both primary and casual partners during this time and are counted in each category.
Table 1 shows that nearly one-third (32.1%) of mentally ill men and 10% of mentally ill women who were sexually active had multiple (three or more) partners in the past 12 months. Among the study sample, men were significantly more likely to have had multiple sexual partners than women (OR = 2.9, 95% CI = 1.0–8.12).
Both men and women with mental illness were less likely to use condoms in a primary relationship than a casual relationship (Table 2). Almost three-quarters (73.5%) of people who were in a regular sexual relationship never used condoms, while one-fifth (20%) of men and 57% of women who had sex with casual partners never used condoms. Only 52% of men and 14% of women who had sex with casual partners in the last 12 months always used condoms.
Condom use with primary and casual partners among psychiatric outpatients
The only data from Ross [12] that can be directly compared with the current study is on the prevalence of male homosexual sex. Rates of male-to-male sex among people with mental illness were lower than reported by Ross [12] for the general population (3.7% cf. 6.1%). Only 1% of women in the current study reported having sex with a bisexual man in the past 12 months.
Sixteen per cent of men and 9% of women with mental illness reported that they had had sex in the past year with someone whom they believed had a lot of other sexual partners. Five per cent of mentally ill men and 3% of women reported that they had had sex with an injecting drug user in the last 12 months and one person reported that they had had sex with someone they knew to be HIV positive.
Illicit drug use risk factors
Table 3 shows that people with mental illness were much more likely than a community sample to report that they had used heroin in the previous 12 months, that they had ever injected illicit drugs and/or that they had recently injected illicit drugs. The only category for which the mentally ill recorded a lower prevalence of drug use than the general population was among women aged 30–39. Mentally ill women in their 30s recorded zero prevalence in terms of recent heroin use and recent injecting drug use. The higher lifetime prevalence of women with mental illness injecting illicit drugs was not significant (OR = 3.2, 95% CI = 0.24–13.1).
Prevalence (%) of heroin and injecting drug use for a mentally ill sample and the 1998 National Drug Strategy Household Survey
People with mental illness were seven times more likely than the general population to report using heroin in the last 12 months (OR = 7.1, 95% CI = 3.9–13.0). The mentally ill were almost eight times more likely to report having ever injected illicit drugs (OR = 7.7, 95% CI = 5.1–11.1) and 8.5 times more likely to report injecting illicit drugs in the previous 12 months (OR = 8.6, 95% CI = 4.8–15.5).
The highest rates of heroin and injecting drug use for both men and women occurred in the 20–29 age group for both the general population and among the mentally ill.
For men, there was an inverse relationship between the prevalence of drug-related risk factors for HIV and age. This relationship was also true for women in the general population, but not for women with mental illness, due to the low prevalence of IDU among women between 30 and 39 years. With the exception of mentally ill women between 30 and 39, there was a decline in drug-related behaviour with increasing age.
There is no comparative data available from the 1998 National Drug Strategy Household Survey [11] in relation to sharing needles or other injecting equipment. The lifetime prevalence of people with mental illness ever sharing needles was 7.4%. Prevalence rates were highest in the youngest age group and were higher in women than men. Nine per cent of males and 14% of females between 20 and 29 years reported sharing needles at least once. Although only 2% of the overall sample reported sharing needles in the past 12 months, 6% of young men and almost 10% of young women had shared needles recently.
Testing
More than one-third (36.8%) of people with mental illness reported that they had been tested for HIV antibodies. A substantial proportion (12%) did not know whether or not they had undergone a HIV antibody test. People who had ever injected illicit drugs were significantly more likely to have had an HIV test than people who had never injected (OR = 6.6, 95% CI = 2.5–17.2). One-quarter of participants reported that they had been tested for HCV. One-fifth (21.4%) of patients had not heard of hepatitis C and did not know if they had been tested. Patients who had ever injected illicit drugs were significantly more likely to report that they had been tested for hepatitis C (OR = 9.6, 95% CI = 3.8–24.0).
Discussion
The difficulties in conducting sensitive research on sexual behaviour is demonstrated by the paucity of studies in the area. Studies of sexual behaviour are typically confined to special subgroups such as gay men or secondary school students and large-scale, population-based studies are limited. The 1988 study conducted by Ross [12] provides the only Australian population-based data available for comparison. Ross [12] reported prevalence rates for risk factors, such as homosexual sex for both men and women, and sex with a prostitute. However, Ross [12] did not collect other information on prevalence of multiple sexual partners or the use of condoms. Moreover, he did not differentiate between primary and casual sexual partners. These discrepancies in data collection, together with the lengthy time period between the two studies, imposes some limitation on comparisons between the mentally ill in the current sample and the general population in the study by Ross [12].
Although people with chronic mental illness in this study are less likely to be sexually active than people in the general population, almost half of the study sample had been sexually active in the 12 months prior to the interview. It has been suggested that the mentally ill are asexual [13], and this belief may have contributed to the lack of attention within mental health settings to HIV risk among psychiatric patients. However, the results of this study are consistent with a previous study by Cournos et al. [14]: both clearly show that sexual activity is prevalent among the mentally ill.
The sexual relationships of mentally ill men were characterized by a high prevalence of casual sexual partners. Although women were more likely to be in a sexual relationship with a primary partner than were men, 14% of women also reported having casual sexual partners in the previous year. Among people who were sexually active, one-third of men and 10% of women with mental illness had more than three sexual partners over the last year. This small group of psychiatric patients are at increased risk of HIV or other sexually transmitted disease infection because as the number of sexual partners increases, risk of exposure to infection also increases. The rate of casual sex among the mentally ill highlights the importance of mental health workers taking a full sexual history from patients in order to identify those patients at risk.
Unlike other studies on the prevalence of HIV risk factors, this study distinguished between casual and primary partners and examined the use of condoms [7, 12]. This distinction revealed that only 14% of mentally ill women who had sex with casual partners always used condoms.
The major mode of HIV transmission among women in Australia has been via sex with high-risk men [15]. Although only a small proportion of women reported having sex with high-risk men it is highly likely that women with multiple casual partners are unaware of either the sexual history or seroprevalence status of casual partners. Therefore, the proportion of women who had sex with high-risk (IDU or bisexual) men was probably grossly underreported in this study. The high prevalence of unprotected sex with casual partners reflects the sexual vulnerability of women with mental illness and suggests that women with mental illness may be at even greater risk of HIV than their male counterparts. The sexual vulnerability of women with mental illness is underscored by studies such as that conducted by Coverdale and Turbott [16] which found that mentally ill women were significantly more likely to be sexually abused or coerced into sex than women in the general community and mentally ill men. Because the current study did not collect information regarding whether sex was consensual or coerced it is possible that women who were forced into non-consensual sex did not report themselves as sexually active, thus underestimating the real prevalence of sexual encounters and the subsequent risk of HIV and hepatitis C.
A lower prevalence of male-to-male sex in the past 12 months was reported in this study than in the studies by Ross [12] or Thompson et al. [7]. In an attempt to reduce recall bias patients were only asked about their sexual history for the past year. If patients were asked about male-to-male sex in the last 10 years, as did the study by Thompson et al. [7], the prevalence rate would probably have been higher. Given that over half of the sample had been hospitalized for psychiatric illness in the preceding 12 months, and 79% had a primary diagnosis of schizophrenia, it is reasonable to assume that the opportunity for sexual relations was limited by being acutely ill. Unlike mania, psychotic episodes are not generally a cause of increased sexual activity. On this basis, it is possible that the lifetime prevalence of maleto- male sex among the mentally ill sample is equivalent to Thompson et al. [7] which was around 13%. However, the low proportion of men in the study admitting to male-to-male sex indicates the difficulty of evaluating effectiveness of interventions for this high-risk behaviour. It is recommended that future studies include items on both current and past sexual behaviour.
People with chronic mental illness in this study were much more likely to use heroin than other people and they were also much more likely to have a history of IDU. It is of major concern that 13% of young people (20–29 years) with mental illness had injected illicit drugs in the 12 months before the interview. Injecting drug use is the second major route of HIV transmission in Australia and accounts for around 8% of cases, although approximately half of these were men who also had a history of sex with other men [1]. Injecting drug use is also a primary route of transmission for HCV [1]. Fifty per cent of people attending needle and syringe exchange programs in Australia in 1998 had the HCV. Epidemiological data shows that HCV prevalence among people who had injected drugs for less than 3 years was 20%. This rose to over 60% for people who had injected for more than 6 years [1].
The prevalence of ‘hard’ drug use in both the mentally ill and the community typically declines with age. However, in all age groups the mentally ill were more likely to use heroin and to inject illicit drugs than the general population. The results from this study are consistent with a wide body of literature showing that substance use is much higher among the mentally ill [17, 18]. Although it is recognized that drug use is prevalent in people with chronic mental illness, attention is usually concentrated on how substance use impacts on psychiatric symptoms and less attention is given to how it may affect their physical health. This study demonstrates that neglecting this latter relationship places the chronically mentally ill IDU at great risk of both HCV and to a lesser extent HIV/AIDS.
The prevalence of heroin and IDU among people with chronic mental illness is likely to increase as patients currently in their 20s with high drug exposure move into the older age groups and are replaced by a younger cohort for whom acceptability of and access to recreational drugs also increases. Continual increases in the prevalence of intravenous drug use may ultimately force us to reconsider what are normal levels of IDU. If such projections are realized there will be an increased need for education, preventative interventions and treatment of the mentally ill for physical diseases transmitted through IDU.
In their 1995 article, ‘Psychiatric patients and HIV infection: a new population at risk?’ Stefan and Catalan [3] noted an increased prevalence of HIV infection among psychiatric patients compared with the general population. Stefan and Catalan [3] suggested that issues relating to HIV/AIDS are likely to assume increased importance in psychiatric practice in the future. The current study supports their warning and the suggestion that the chronic mentally ill should be regarded as a high-risk group for HIV infection. Furthermore, the alarming rates of IDU shown in this cohort illustrates that concern should not be limited to HIV/AIDS, but extended to HCV. It is essential that adequate resources and strategies are targeted to the mentally ill as they are for other high-risk groups.
Footnotes
Acknowledgements
The authors are grateful for the support of the Managers, staff and clients of the four Area Mental Health Services who participated in this project. The study was funded by a project grant from the Victorian Health Promotion Foundation.