Mental health and sexual risk behaviours in a South African township: A community-based cross-sectional study

Summary

Objectives

Despite the high prevalence of both mental illness and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) in developing countries, there are few data on the association between different forms of mental illness and sexual risk behaviours in resource-poor settings. The objective of this study was to examine the association between mental illness and HIV risk behaviours in a South African township.

Study design

A cross-sectional study was performed among 645 individuals living in households selected at random.

Methods

A self-administered translated questionnaire investigated sexual risk behaviours [including sexual partners, condom use, casual sexual contacts, and sex in exchange for money, drugs or a place to stay (transactional sex)], depression (measured using the Center for Epidemiological Studies Depression Scale), alcohol abuse (from the Alcohol Use Disorders Identification Test), and post-traumatic stress disorder (based on the Life Event Checklist).

Results

Of the 645 individuals who completed the survey, 33% reported depression, 17% reported alcohol abuse, and 15% reported post-traumatic stress disorder. After adjusting for demographic characteristics, the presence of any of these three conditions was strongly associated with experiences of forced sex [adjusted odds ratio (AOR) 2.53; 95% confidence intervals (CI) 1.60–4.02], transactional sex (AOR 2.88; 95% CI 1.29–6.48) and increased condom use (AOR 2.07; 95% CI 1.32–3.25).

Conclusions

These findings emphasize the substantial burden of mental illness in this setting, and its association with forced and transactional sex. The temporal nature of these associations is not always clear from this cross-sectional study, and additional prospective research is required. Public health interventions are needed to address the dual burden of HIV/AIDS and mental illness in this and similar settings.

Introduction

With over 25 million people across the continent already infected,¹ the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) epidemic is a major health concern facing countries of sub-Saharan Africa. While a range of structural conditions, such as migrant labour, high levels of poverty and gender inequality, contribute to the spread of the epidemic throughout Africa, most research to date investigating the determinants of the HIV epidemic has focused on individual-level risk factors.² However, little attention has been given to the impact of factors related to mental illness, such as depression, trauma and substance abuse, on HIV risk behaviours.3, 4

Several studies have suggested that HIV risk behaviours may be associated with mental illness, including depression and post-traumatic stress disorder (PTSD).5, 6, 7, 8, 9, 10, 11 Despite the increasing concern about the contribution of mental illness to the burden of disease in developing countries,¹² and growing evidence that most mental health problems in these settings go untreated,¹³ there are few data from resource-poor countries on the potential links between these conditions and sexual risk behaviours.

Mental illness may be a particularly important factor shaping high-risk sexual behaviours in South Africa. High levels of violence are well documented,14, 15 including sexual, physical and domestic abuse,¹⁶ which have in turn been associated with PTSD, depression and substance abuse.17, 18 Several studies among adolescents have shown that sexual risk behaviours are associated with alcohol and drug abuse,¹⁹ but the association between sexual behaviours and other forms of mental illness, such as depression and PTSD, has received little attention.

Given the lack of data on the relationship between mental illness and individual risk behaviours, this study used data from a community-based survey to examine the association between HIV-related sexual risk behaviours and three key psychiatric disorders that are prevalent in the South African context: depression, alcohol abuse and PTSD.20, 21 It was hypothesized that different measures of mental illness would be associated with increased risk-related behaviours, such as low levels of condom use, exchange of sex for money, sex under the influence of alcohol and drugs, or sex with casual (rather than regular) sexual partners.