Prevalence of suicidal ideation and associated factors ...

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Original research article

Prevalence of suicidal ideation and associated factors among HIV-positive MSM in Anhui, China

International Journal of STD & AIDS 0(0) 1–8 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462414544722 std.sagepub.com

Yi-Le Wu1,*, Hui-Yun Yang1,*, Jun Wang1, Hui Yao2, Xue Zhao1, Jian Chen1, Xiu-Xiu Ding3, Hong-Bo Zhang1, Peng Bi4 and Ye-Huan Sun1

Abstract Objective: The aim of this study was to investigate the prevalence and factors associated with suicidal ideation among HIV-positive men who have sex with men (MSM) in Anhui, China. Methods: A cross-sectional study was conducted to recruit HIV-positive MSM in Anhui, China. A total of 184 HIVpositive MSM gave informed consent and completed the interview. Correlates of suicidal ideation were assessed using multivariable logistic regression. Results: Fifty-seven (31%) of HIV-positive MSM had suicidal ideations within six months before the interview. Multivariable analyses showed that known their HIV status in the past 12 months (adjusted odds ratio (AOR) ¼ 3.4, 95% CI ¼ 1.6–7.3), perceived HIV stigma (AOR ¼ 2.4, 95% CI ¼ 1.1–5.2), depression symptoms (AOR ¼ 2.6, 95% CI ¼ 1.1–5.9) and anxiety symptoms (AOR ¼ 2.7, 95% CI ¼ 1.2–6.1) were significantly associated with the suicidal ideation among HIV-positive MSM. Conclusion: The results indicated that suicidal ideation was common among HIV-positive MSM in Anhui, China. There is an urgent need to establish psychological counselling services among HIV-positive MSM in China. Targeting on these potential risk factors could be an effective approach to reduce the suicide risk among this high-risk subgroup by the implementation of early intervention measurements.

Keywords Men who have sex with men, suicidal ideation, depression, anxiety, HIV Date received: 11 March 2014; accepted: 30 June 2014

Introduction Epidemiological survey showed that the estimated number of people who are living with Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) were 780,000 by the end of 2011 in China.1 The most-at-risk subgroups of HIV infection have been changed from injection drug users and plasma donors to heterosexual transmission via commercial sex workers and homosexual transmission among men who have sex with men (MSM).1–3 HIV is now spreading at an alarming rate with a substantial increase of prevalence among MSM throughout China, and the proportion of reported HIV cases among MSM increased from 1.77% in 2000 to 5.98% in 2011.4 It is estimated that, 12.2% of new HIV infections were

through homosexual contact among MSM in 2007,5 but the proportion rose to 29.4% in 2011.6 Current estimates suggested that homosexual transmission 1 Department of Epidemiology and Statistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China 2 Center for Disease Control and Prevention of Hefei City, Hefei, China 3 Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China 4 Discipline of Public Health, the University of Adelaide, Australia

*Yi-Le Wu and Hui-Yun Yang contributed equally to this work. Corresponding author: Ye-Huan Sun, Department of Epidemiology and Statistics, School of Public Health, Anhui Medical University, No. 81 Meishan Road, Hefei 230032, Anhui, China. Email: [email protected]


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among MSM accounted for 17.4% of all notified HIV cases in China.4,6 People living with HIV/AIDS (PLWH) face several challenges including the medical management of their disease, stigma, discrimination and psychosocial pressure associated with HIV infection.7 HIV/AIDS has been recognized as one of potential predictors of suicidal behaviour. Suicidal ideation refers to all thoughts that may be interpreted through behaviour to endanger or threaten one’s own life.8 Some studies reported higher rates of suicidal ideation among HIV-positive individuals than those without HIV infection.9–13 However, other studies were not able to detect the difference.14,15 To our knowledge, a few of studies reported the high prevalence of suicidality in PLWH in China: 43.1% among HIV-positive injection heroin users,16 34% for the 12-month prevalence of suicidal ideation and 8% for making a suicidal attempt among HIV-positive former blood and/or plasma donors,11 and 35.4% for suicidality among HIV-positive patients in rural China.17 Studies from other countries have suggested that the following potential factors might be associated with suicidality in PLWH: socio-demographic factors (e.g. age, gender and ethnicity), psychological distress or problems (e.g. depressive disorder, generalised anxiety disorder, previous attempted suicide and family history of suicide attempts), psychosocial factors (e.g. employment, food insecurity, exhaustion of financial resources, substance abuse, physical abuse, quality of life and HIV-related stigma) and clinical factors (e.g. psychological symptoms, and AIDS diagnosis).8,9,13,18–20 Previous Chinese studies had suggested that gender, major depressive symptoms, poor social support, family function and spouse’s HIV status were associated with suicidal ideation in PLWH.11,17 Little research has investigated the prevalence and factors associated with suicidal ideation among HIVpositive MSM, and most of such studies were conducted in developed countries.9,15,21 Elsewhere, HIV infection and homosexual behaviour have independently been associated with suicidality.9,10,22,23 Yet, studies have often overlooked HIV-positive MSM in China. The alarming HIV epidemic among MSM in China makes this group at the most risk, not only physically because of HIV but also psychologically due to stigma against homosexuality.24 The traditional Chinese culture makes most people not openly endorse homosexuality behaviours; therefore MSM are often a highly stigmatized group in the society.25 One recent study revealed that MSM struggled with feelings of shame and believed that others possessed stigmatizing attitudes on homosexuality.26 Consequently, HIV-positive MSM are suffering more pressure from both stigma of homosexuality and HIV infection and likely to be

more vulnerable. However, no research has investigated the prevalence and factors associated with suicidal ideation among Chinese HIV-positive MSM. The objective of this study was to investigate the prevalence and possible associated risk factors of suicidal ideation among a Chinese sample of HIV-positive MSM. It was hypothesized that suicidal ideation would be high in HIV-positive MSM. Potential factors such as socio-demographic characteristics, sexual behaviours and psychological factors may contribute to suicidal ideation among this specific subgroup.

Method Subjects and methods This cross-sectional study was conducted between April and July of 2013 in Anhui, China. A consecutive sample including 200 registered adult PLWH who were MSM were selected from three cities (Hefei, Maanshan and Wuhu) in Anhui, China with help from the local Center for Disease Control and Prevention (CDC). All the HIV-positive participants had been diagnosed and registered with the Chinese National Information System for AIDS Prevention and Control (CNISAPC), which is the official entry point for HIV/AIDS patients to receive the regular follow-up and health care according to national guidelines. PLWH who were MSM were initially targeted through the registration information of local CDC, and the MSM status was then further confirmed by themselves. Finally, 184 of index PLWH gave informed consent to participate in the study. The response rate was around 92%. Eligibility criteria for the HIV-positive participants were: (a) diagnosed with HIV-positive at least six months previously (in this study, we aimed to investigate the suicidal ideation of HIV-positive MSM within six months before the interview. In order to accord with this investigated period, HIV positive MSM diagnosed at least six months before the survey were recruited); (b) 18 years of age or older; (c) self-identified as a man who has sex with men and (d) resident in Anhui during the study period. All the study participants were able to provide written informed consent. The interviewers confirmed that participants understood all aspects of the study through explaining the research purposes, procedures and possible outcomes. Participants were also advised that they could withdraw from the study at any time. A contact phone number from the ethics committee was provided for possible complaint. Participants gave their written informed consent and each was compensated with 50 RMB (approximately US$8) after the survey. Participants were not aware of this payment when they participated. This study was approved by the


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Ethics Committee of Anhui Medical University, Hefei, China.

Measures Face-to-face interviews were conducted by public health postgraduate students who were trained how to use standard methods before the interview. The data collection instruments consisted of various structured modules, which included the following: Suicidal ideation and attempted suicide. Suicidal ideation and attempted suicide in the last six months were asked. The definition of suicidal ideation and attempt referred to previous study.27 The question on suicidal ideation asked: ‘‘during the last 6 months, have you ever had thoughts of taking your own life, even if you would not actually do it?’’, and attempted suicide asked: ‘‘have you ever attempted to take your own life in the last 6 months?’’ (response option was 1 ¼ yes and 2 ¼ no). Socio-demographic and clinical factors. A brief questionnaire was used to collect the information of participants’ age, education level, income, employment status, marital status, living situation (alone, parents/ spouse/children, others) and the amount of time that had elapsed since he learned of his HIV status. To correspond to a previous study aiming to investigate the suicidality in HIV/AIDS,28 we used less than 12 months and greater than 12 months to recode this continue variable into categorical variable. Sexual behaviours. This self-report measure assessed a variety of factors related to sex, including sexual orientation, the number of sex partners, sexual contact with male partners and female partners, and condom use in past six months. Perceived HIV stigma. The degree of HIV stigma experienced by participants was assessed using the HIV Stigma Scale.29 With each item, participants were required to respond to rate their stigma experience using a scale of 1 (strongly disagree) to 4 (strongly agree). A total score was calculated by computing the sum of the 40 items. Higher scores indicated increased HIV stigma experience. Referring to Genberg et al.,30 in this study, the distributions of the total scores were divided into two groups such as none/moderate and severe perceived HIV stigma based on the 75th percentile cut-off values. The Cronbach alpha coefficient for current sample was 0.94. Depression symptoms. The Center for Epidemiological Studies Depression Scale (CES-D Scale) was used to

assess participant’s depression symptoms.31 This questionnaire is comprised of 20 items to assess various depressive symptoms experienced in the past week. Items were answered on a 4-point scale ranging from 0 (not at all) to 3 (extremely). A cut-off of 22 or greater of the CES-D scale score was used to define significant depression symptoms. The Cronbach alpha coefficient was 0.85 for this sample. Anxiety symptoms. The level of anxiety was measured using the Self-Rating Anxiety Scale (SAS).32 The SAS is a 20-item self-report measure requiring participants to rate each item as it applies to their personal experience of the past week using a four-point scale from 1 (never) to 4 (always). The total raw scores range from 20 to 80. A SAS standardized score >40 indicated significant anxiety symptoms. The Cronbach alpha coefficient was 0.92 for this sample. Self-esteem. The Rosenberg Self-Esteem Scale is a 10-item self-report measure.33 Items were answered on a 4-point scale ranging from 0 (strongly disagree) to 3 (strongly agree). A higher score indicated higher selfesteem, whereas a lower score (34 Education level High school graduate At least some college Monthly income (RMB) < ¼ 2000 >2000 Employment Unemployed/retired/students Employed Marital status Ever married Single Living with whom Alone Parents/spouse/children Others Time knew HIV status Up to 12 months More than 12 months

Suicidal ideation (n, %)

OR

95% CI

47 (25.5) 79 (42.9) 58 (31.5)

13 (27.7) 27 (34.2) 17 (29.3)

1.0 1.4 1.1

0.6–3.0 0.5–2.6

88 (47.8) 96 (52.2)

31 (35.2) 26 (27.1)

1.0 0.7

0.4–1.3

90 (48.9) 94 (51.1)

32 (35.6) 25 (26.6)

1.0 0.7

0.4–1.2

31 (16.8) 153 (83.2)

12 (38.7) 45 (29.4)

1.0 0.7

0.3–1.5

77 (41.8) 107 (58.2)

28 (36.4) 29 (27.1)

1.0 0.7

0.4–1.2

65 (35.3) 93 (50.5) 26 (14.1)

21 (32.3) 30 (32.3) 6 (23.1)

1.0 1.0 0.6

0.5–2.0 0.2–1.8

83 (45.1) 101 (54.9)

34 (41.0) 23 (22.8)

2.4 1.0

OR: unadjusted odds ratio; CI: confidence interval.

1.2–4.5


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Table 2. Correlates of sexual behaviours and suicidal ideation among HIV-positive MSM. Univariate analysis Number in study Suicidal ideation (n, %) (n, %) OR 95% CI Sexual orientation Homosexual Bisexual Heterosexual/undecided Sex with men (in past 6 months) No Yes Sex with women (in past 6 months) No Yes Had sex with anyone (in past 6 months) No Yes Sex with a casual partner (in past 6 months) No Yes Paid money for sex (in past 6 months) No Yes Consistent condom use (in past 6 months, n ¼ 89) No Yes

114 (62.0) 57 (31.0) 13 (7.0)

35 (30.7) 18 (31.6) 4 (30.8)

1.0 1.0 1.0

0.5–2.0 0.3–3.5

102 (55.4) 82 (44.6)

32 (31.4) 25 (30.5)

1.0 1.0

0.5–1.8

169 (91.8) 15 (8.2)

52 (30.8) 5 (33.3)

1.0 1.1

0.4–3.5

95 (51.6) 89 (48.4)

30 (31.6) 27 (30.4)

1.0 0.9

0.5–1.8

152 (82.6) 32 (17.4)

48 (31.6) 9 (28.1)

1.0 0.8

0.4–2.0

180 (97.8) 4 (2.2)

56 (31.1) 1 (25.0)

1.0 0.7

0.1–7.3

28 (31.5) 61 (68.5)

10 (35.7) 17 (27.9)

1.0 0.7

0.3–1.8


Table 3 presents the psychological characteristics of HIV-positive participants, of which 59 (32.1%) experienced severe HIV-related stigma. The prevalence of psychiatric symptoms/problems including depression and anxiety in the prior six months was 42.9% and 32.1%, respectively. Among all HIV-positive participants, 13.6% had low levels of self-esteem. Results from the univariate logistic regression analysis indicated that HIV-positive MSM who perceived severe HIV-related stigma (OR ¼ 3.0, 95% CI ¼ 1.5–5.8, P < 0.01), with higher levels of depression symptoms (OR ¼ 4.7, 95% CI ¼ 2.4–9.2, P < 0.01), anxiety symptoms (OR ¼ 4.2, 95% CI ¼ 2.2–8.2, P < 0.01) and low levels of self-esteem (OR ¼ 3.4; 95% CI ¼ 1.4–8.1, P < 0.01) were at increased risk of reporting the current suicidal ideation.

Factors associated with suicidal ideation at multivariate analysis Using all the variables which were significant at P < 0.10 in the univariate analysis as candidate variables, the results from the final multivariable logistic

regression models suggested that known HIV status in the past 12 months (adjusted odds ratio (AOR) ¼ 3.4, 95% CI ¼ 1.6–7.3, P < 0.01), perceived HIV stigma (AOR ¼ 2.4, 95% CI ¼ 1.1–5.2, P ¼ 0.02), with higher levels of depression symptoms (AOR ¼ 2.6, 95% CI ¼ 1.1–5.9, P ¼ 0.03) and anxiety symptoms (AOR ¼ 2.7, 95% CI ¼ 1.2–6.1, P ¼ 0.02) were statistically significant risk factors for suicidal ideation among HIV-positive MSM (Table 4).

Discussion This study investigated the prevalence and potential risk factors of suicidal ideation among HIV-positive MSM in Anhui, China. To our knowledge, this is the first such research among HIV-positive MSM in China. The results showed that a high prevalence of suicidal ideation was present among the HIV-positive MSM (31%), which is similar to HIV-positive population of 34% in rural China11 and 34.7% in Nigeria.12 Prevalence rates of current suicidal ideation and attempts in HIV-positive MSM were obviously higher than the lifetime prevalence rate of 3.1% and 1%,


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Table 3. Correlates of psychological factors and suicidal ideation among HIV-positive MSM. Univariate analysis

Perceived HIV stigma None/moderate Severe (>75 percentile) Depression symptoms No Yes Anxiety symptoms No Yes Self-esteem Low Normal/high

Number in study (n, %)

Suicidal ideation (n, %)

OR

95% CI

125 (67.9) 59 (32.1)

29 (23.2) 28 (47.5)

1.0 3.0

1.5–5.8

105 (57.1) 79 (42.9)

18 (17.1) 38 (48.1)

1.0 4.7

2.4–9.2

125 (67.9) 59 (32.1)

26 (20.8) 31 (52.5)

1.0 4.2

2.2–8.2

25 (13.6) 159 (86.4)

14 (56.0) 43 (27.0)

3.4 1.0

1.4–8.1


Table 4. Final multivariate model of risk factors for suicidal ideation among HIV-positive MSM. Multivariate analysis

Time knew HIV status Up to 12 months More than 12 months Perceived HIV Stigma None/Moderate Severe (>75 percentile) Depression symptoms No Yes Anxiety symptoms No Yes

AOR

95% CI

3.4 1.0

1.6–7.3

1.0 2.4

1.1–5.2

1.0 2.6

1.1–5.9

1.0 2.7

1.2–6.1

AOR: adjusted odds ratio; CI: confidence interval.

respectively, among general metropolitan population in China.34 The findings suggest that there is an urgent need to establish psychological counselling services and regularly screen for suicidal ideation among HIVpositive MSM in China. The results from present study indicated that there was an increased risk of suicidal ideation among those who knew HIV status in the past 12 months. This is consistent with an earlier study, which found that most HIV-positive individuals made their first suicidal attempt/ideation immediately after their HIV diagnosis, with 42% within a month and 27% within the

first week.35 It is reasonable that, at the beginning stages of coping with HIV diagnosis, suicide ideation may arise as the infected individual begins to envision frightening images of a future life with AIDS.36 However, the suicidal ideation and attempt often provoked a process of coping with HIV disease, leading to a redefinition of the meaning of HIV, enhancing one’s sense of control over life.35 Finally, they would adapt/ be resilient to the situation and seek a new commitment to life and personal goals. This highlights the importance that HIV clinicians should recognize the peak period soon after HIV diagnosis as an important determinant of suicidal ideation, and provide more mental supports to help HIV-positive MSM who have recently been diagnosed with HIV get through the crisis around suicidal ideation or attempt in coping with HIV infection. This study also discovered that those who had current suicidal ideation are more frequent among participants who have perceived severe HIV stigma. Even in contemporary China, suicidal thoughts are still most likely to result from psychological pressure and failure of being accepted by mainstream society.37 A recent study revealed that 27% of PLWH had experienced severe forms of stigma.7 HIV-related stigma has the potential to markedly harm the health and well-being of PLWH,38 and may cause many possible consequences such as depression, anxiety, loss of social support, loneliness and decreased self-esteem.28 Those adverse consequences of stigma may exacerbate the stress contributing to suicidal ideation. For HIV-positive individuals, suicide may be considered as a viable option to end their physical and emotional pain of the disease and its resulting discrimination.39


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Those participants who had current suicidal ideation reported significant depression and anxiety symptoms more frequently. Depression and anxiety are often highly prevalent among HIV-positive individuals.40,41 Previous studies have also indicated an association between suicidal ideation in HIV/AIDS and depressive and anxiety disorders.18,40 The significant depression and anxiety symptoms are frequently found to coexist with long-standing chronic medical conditions, and to be associated with barriers to treatment and worse psychiatric outcomes, including treatment resistance and increased risk for suicide.42 Although psychological distress is common among HIV-positive individuals, mental health services are often not adequately available as part of care and treatment services in China. At present, a greater access to psychological counselling services among this infected population would be practical and feasible. Some limitations of the present study need to be taken into account when interpreting the study results. First, cross-sectional study design makes it difficult to determine the direction of the causality between the risk factors and suicidal ideation. Therefore, longitudinal studies which could establish the causal direction between the investigated factors and suicidal ideation are warranted. Second, the present study was conducted in limited areas in Anhui Province, China. Inevitably, the generalizability of the study findings is restricted. The further research conducted into the broad areas in China is helpful. Third, using an interviewer-administered questionnaire might increase the risk of the social desirability. Consequently, it might underestimate the real risk behaviour among this specific population. The results from this study have significant public health policy implications and will also affect service providers to refine their health service guidelines. For example, the assessments and interventions for suicide and mental health patients should include this specific vulnerable group. Although longitudinal studies are required to replicate these results, the findings from this study will assist with identifying HIV-positive MSM who may be at an increased risk for suicidal ideation, so that they could be screened regularly and receive psychological treatment when appropriate. Besides, the findings will also identify potential targets to reduce suicide risk through the treatment of psychiatric disorders such as depression and anxiety, and fundamentally promote adaptation and resilience capacity to living with HIV/AIDS. Moreover, reducing HIV/AIDSrelated stigma and teaching stress management such as general suicide education should be included in health education or intervention programs among this subgroup population.

Acknowledgements We appreciate the contribution of all people who participated in this study. We would like to thank the staff from Centers for Disease Control of Hefei, Maanshan and Wuhu for their help in data collection during this research.

Conflict of interest The authors declare no conflict of interest.

Funding This research was supported by the Global Fund to Fight AIDS in China Programs 2012.

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