Body Image and Risk Behaviors in Youth with HIV

Abstract

Body image concerns are common among people living with HIV. Among adults with HIV, body image concerns have been shown to be related to risky sexual behaviors; little research has been conducted among youth living with HIV (YLWH). The current study examined the predictors, including body image, of sexual risk behaviors among YLWH. Adolescents from a single clinic (n = 143; age range, 16–24 years; 69% male; 95% African American) completed a computerized self-report survey to assess demographic, behavioral, and body image domains. Demographic and clinical data were abstracted from the medical record. Logistic regression analyses assessed associations between risk factors and risky sexual behaviors. Results indicated that YLWH who reported less favorable body image perceptions (p = 0.04) and more sexual partners (p = 0.05) were less likely to use condoms during their last sexual encounter. YLWH with six or more sexual partners were more likely to use drugs or alcohol during their last sexual encounter (p = 0.03). A belief that their HIV medications changed their body physically (p = 0.05), history of HIV-related complications (p = 0.03), an undetectable viral load at their most recent clinical laboratory draw (p = 0.01), and having a high school diploma or equivalent (p = 0.001) were independently associated with disclosure of participant's HIV status to a romantic/sexual partner. Findings suggest that body image perceptions may influence risky sexual behavior in YLWH. Further study is warranted to understand and intervene upon this relationship to improve individual and public health outcomes.

Introduction

Concerns about body image are a common occurrence among adults living with HIV.¹ Body image among adults living with HIV has also been shown to be related to risky sexual behavior.^2,3 Multiple physical, psychosocial, and cultural factors influence one's body image. In turn, body image may impact upon an individual's engagement in HIV-related self-care behaviors (e.g., transmission risk reduction, and medication adherence). Emerging evidence among adults living with HIV has highlighted the role body image disturbance may exert on HIV self-care behaviors that influence both individual and public health related outcomes; however, there is sparse evidence among youth living with HIV (YLWH).²

YLWH are prone to struggle with health and/or poor body image, as well as engage in sexual transmission risk behaviors.^4,5 Body dissatisfaction has been shown to contribute to negative emotions and psychosocial problems in YLWH such as depressive symptoms, which among YLWH have been associated with reduced medication adherence and increased risk behaviors.^6
–8 This is of concern given that youth accounted for ∼26% of new HIV infections in the United States in 2010.⁹ As a result, research is urgently needed examining novel pathways that predict HIV transmission risk among YLWH to inform effective intervention development.

High-risk sexual behaviors among people living with HIV can have detrimental individual and public health level consequences.¹⁰ Research has shown a relationship between body image and sexual risk behaviors across multiple age, ethnic, and sexual preference groups.¹¹ Poor body image may impact condom self-efficacy, increasing one's risk of acquiring or transmitting HIV.¹² Evidence suggests that more YLWH engage in risky sexual behaviors compared to adults with HIV.¹³ In another study examining risk behaviors among YLWH, almost half of youth reported engaging in unprotected sex since learning they had HIV.¹⁴ In addition to adolescent risk factors such as use of social media to connect with partners, low concern about HIV infection, and infrequent discussion about HIV status,¹⁵ body image may play a role in increasing risks. Despite the recognized relationship between body image and high-risk sexual behavior, studies examining this among YLWH are lacking and urgently needed.

To address this identified gap in the literature, the current study aimed to examine the predictors, including body image measures, of sexual risk behaviors among YLWH. It was hypothesized that negative body image perceptions would be significantly related to increased HIV sexual transmission risk behaviors. For the purposes of this study, youth will be defined as those between the ages of 16 and 24 years old.

Methods

Participants and procedure

This study was a secondary analysis from an existing dataset. The dataset used was collected as a cross-sectional exploratory pilot study of body image in a sample of YLWH. The purpose of the original study¹⁶ was to explore self-reported body image, health behaviors, clinical, and sociodemographic factors among YLWH.

Participants were recruited using a census approach from an adolescent infectious diseases (ID) clinic in the Mid-southern United States. Inclusion criteria included the following: youth (aged 16–23 years old inclusive) with documented diagnosis of HIV infection, awareness of HIV diagnosis, primary language was English, and ability to provide informed consent. Youth with significant motor, sensory, or other impairments that precluded participation in the study as determined by the clinic psychologist were excluded. Participants completed an audio computer-assisted self-interview (ACASI)¹⁷ in a private area of the clinic and received $10 compensation for their time and effort. The electronic survey was reviewed by the ID clinic's youth community advisory board, and recommendations were incorporated into the final script. Relevant demographic and clinical data were also abstracted from the youth's medical record. This study was approved by the clinic site's institutional review board.

Measures

Demographics questionnaire

Participants were asked several demographic questions, including gender, education status, sexual identity, sexual history [e.g., men who have sex with men (MSM)], and race. Social/environmental questions were also collected and included with whom the participant lives and whether/not they receive public assistance (e.g., public health insurance, food stamps, or other public financial support).

Multi-dimensional Body-Self Relations Questionnaire

The Multi-dimensional Body-Self Relations Questionnaire (MBSRQ) is a well-validated self-report inventory for the assessment of body image.¹⁸ Internal consistency of the subscales on the MBSRQ ranges from α = 0.70–0.91 for male respondents and α = 0.73–0.90 for female respondents. Test–retest reliability estimates ranged from 0.71 to 0.89 for male respondents and 0.74 to 0.94 across subscales at 1-month follow-up for female respondents. The MBSRQ is intended for use with individuals 15 years or older. This study used the MBSRQ-Appearance Scales (AS).¹⁸ The MBSRQ-AS is a shortened 34-item measure from the MBSRQ that consists of five subscales: Appearance Evaluation, Appearance Orientation, Overweight Preoccupation, Self-Classified Weight, and the Body Areas Satisfaction Scale (BASS). To estimate overall body image from this measure, a combination score from the Appearance Evaluation and BASS was derived.¹⁸

Figure Rating Scale

The Figure Rating Scale used for this study is modeled after Stunkard's¹⁹ widely used nine-figure scale. The current version is a culturally relevant measure of body size satisfaction; the figures have hair and facial features resembling people with multi-ethnic backgrounds. It consists of a series of nine schematic figures of varying size. Findings indicate good test–retest reliability and moderate correlations with other measures of body dissatisfaction, eating disturbance, and overall self-esteem.²⁰ Participants were asked to identify which image they find most similar to their current body type, as well as their ideal or preferred body type.

Youth Risk Behavior Survey

The Youth Risk Behavior Survey monitors priority health-risk behaviors and the prevalence of obesity and asthma among youth in the United States.²¹ The Youth Risk Behavior Surveillance System (YRBSS)²¹ includes a national school-based survey conducted by the Centers for Disease Control and Prevention (CDC) and state, territorial, tribal, and district surveys conducted by education and health agencies/governments. The YRBSS monitors six categories of priority health-risk behaviors among youth and young adults, including behaviors that contribute to unintentional injuries and violence; tobacco use; alcohol and other drug use; sexual behaviors related to unintentional pregnancy and sexually transmitted infections, including HIV; unhealthy dietary behaviors; and physical inactivity.²¹ For the purposes of this study, select questions pertaining to sexual behaviors and drug use were included.

Center for Epidemiologic Studies Depression Scale–Short Form

The Center for Epidemiologic Studies Depression Scale–Short Form (CES-D-10) is the abbreviated version of one of the most commonly used self-report depression scales designed for use in clinical and research settings.²² The CES-D-10 has been found to perform, as well as the full item questionnaire.²³ Cronbach's alpha for the CES-D-10 scale reliability has consistently exceeded 0.8, and item-to-total correlations have been low (<0.5).²² High internal consistency also has been reported.^22,23 The range of scores is 0–30 with higher scores representing a more depressed mood. With all 10 items, the CES-D-10 can be regarded as a measure of affect (i.e., the presence of negative affect and, to a lesser extent, the absence of positive affect). A cutoff score of 10 has been recommended for the categorization of depression;²² therefore, those with a score of 10 or higher were categorized as having elevated depressive symptoms for the purpose of these analyses.

In addition to the measures above, participants currently taking antiretroviral (ARV) medications were asked if they believed their ARVs were causing changes to their body. Female participants who were currently prescribed hormonal contraceptives were asked if they believed their birth control medications caused weight loss or weight gain and if they ever stopped taking their birth control medication due to concerns that it was causing body weight changes.

Medical record/chart abstraction

Demographic and health status variables, such as disease and treatment status, laboratory values, and vital signs, were abstracted from the participant's medical record by study staff. Specific values collected for these analyses included: participant's most recent height, weight, and body mass index (BMI). Calculated BMI scores also were categorized based on the CDC standard weight status categories (underweight, normal, overweight, and obese) for BMI.²⁴

Analyses

Descriptive statistics was used to describe and characterize the sample. Associations with risky sexual behaviors were assessed using univariate and multiple logistic regression models. Risk factors with a p-value below 0.1 in univariate logistic regressions were included in multiple logistic regressions, and a backward selection was performed until all remaining factors were significant at the 0.1 level. Data analyses were conducted using SAS version 9.3 and IBM SPSS version 23.

Results

A total of 148 potential participants were approached for study participation. Of these 148, 5 declined to participate due to lack of time or being uninterested in the study. Participants were 143 HIV-infected YLWH with an average age of 20.7 years (SD = 1.98; range = 16.02–23.98 years). The majority was male (69.2%), and 95.1% were black/African American. Approximately 83% of the sample had acquired HIV through behavioral contact and 82.8% of males in the study identified as MSM. The mean BMI for the total sample was 25.3 (SD = 6.13), CD4 count was 653.4 (SD = 312.1), and viral load was 12,782.1 copies/mL (SD = 32,538.5). See Table 1 for further sample characteristics.

Table 1.

Sample Characteristics

	N = 143
Age, median (range)	20.98 (16.02–23.98)
Gender, n (%)
Male	99 (69.2)
Female	44 (30.8)
Race/ethnicity, n (%)
Black	136 (95.1)
White	6 (4.2)
Other	1 (0.7)
Mode of HIV acquisition, n (%)
Perinatal	24 (16.8)
Behavioral	119 (83.2)
MSM, n (%)
Not MSM	17 (17.2)
MSM	82 (82.8)
Prescribed ARVs, n (%)
Yes	108 (75.5)
No	35 (24.5)
Body mass index, mean (SD)	25.3 (6.13)
CD4 absolute, mean (SD)	653.4 (312.1)
CD4 percentage, mean (SD)	30.8 (10.7)
HIV viral load (copies/mL), mean (SD)	12,782.1 (32,538.5)
Average weight (kg), median (range)	69.4 (44.7–159.1)

ARVs, antiretrovirals; MSM, men who have sex with men; SD, standard deviation.

Using a condom at last sexual encounter was associated with the combined appearance evaluation and body areas satisfaction scale (AE BASS) score [odds ratio (OR) 1.93; 95% confidence interval (CI) 0.99–3.77; p = 0.05] and number of sexual partners (OR 0.39; 95% CI 0.16–0.96; p = 0.04), with participants having higher AE BASS combination scores and fewer number of sexual partners being more likely to use a condom during their last sexual encounter (Table 2). Compared to participants with one to five total sexual partners, participants with six or more sexual partners were more likely to use drugs or alcohol during their last sexual encounter (OR 2.49; 95% CI 1.11–5.57; p = 0.03; Table 3).

Table 2.

Factors Associated with Using a Condom During Last Sexual Encounter

	Univariate analyses		Multivariate analyses
	Odds ratio (95% CI)	p	Odds ratio (95% CI)	p
No of sexual partners
One to five people	Ref
Six or more people	0.39 (0.16–0.93)	0.03	0.39 (0.16–0.96)	0.04
Appearance evaluation and body areas satisfaction combination score	2.02 (1.05–3.90)	0.04	1.93 (0.99–3.77)	0.05

CI, confidence Interval.

Table 3.

Factors Associated with Using Drugs or Alcohol at Last Sexual Encounter

	Univariate analyses		Multivariate analyses
	Odds ratio (95% CI)	p	Odds ratio (95% CI)	p
No of sexual partners
One to five people	Ref
Six or more people	2.49 (1.11–5.57)	0.03	2.49 (1.11–5.57)	0.03
Depressive symptoms
No	Ref
Yes	1.94 (0.89–4.24)	0.09

Backward selection analysis eliminated depressive symptoms at p < 0.10 level from the final model shown.

Participants who received their high school diploma or General Education Development (GED) were more likely to have disclosed their diagnosis to a romantic or sexual partner (OR 8.33; 95% CI 2.30–30.23; p = 0.001). Those who endorsed believing that their ARVs had changed their body were more likely to have disclosed their diagnosis to a romantic or sexual partner (OR 2.98; 95% CI 1.0–8.91; p = 0.05). Participants with a history of a HIV related complication (OR 6.18; 95% CI 1.24–30.94; p = 0.03) and an undetectable viral load (OR 4.53; 95% CI 1.40–14.69; p = 0.02) also were more likely to have disclosed their HIV diagnosis to a romantic and/or sexual partner (Table 4).

Table 4.

Factors Associated with Disclosing HIV Diagnosis to Romantic and/or Sexual Partners

	Univariate analyses		Multivariate analyses
	Odds ratio (95% CI)	p	Odds ratio (95% CI)	p
Belief that ARVs have caused physical changes to body
No	Ref
Yes	2.22 (0.88–5.61)	0.09	2.98 (1.00–8.91)	0.05
Received high school diploma or GED
No	Ref
Yes	3.48 (1.39–8.71)	0.01	8.33 (2.30–30.23)	0.001
Undetectable viral load
No (≥ 400 copies/mL)	Ref
Yes (< 400 copies/mL)	2.18 (1.02–4.66)	0.05	4.53 (1.40–14.69)	0.01
History of HIV related diagnosis
No	Ref
Yes	2.40 (0.90–6.46)	0.08	6.18 (1.24–30.94)	0.03
No of sexual partners
One to five people	Ref
Six or more people	2.83 (1.23–6.50)	0.01

Backward selection analysis eliminated number of sexual partners at p < 0.10 level from the final model shown.

GED, General Education Development.

Participants who reported disclosing their diagnosis to their most recent sexual partner (OR 3.37; 95% CI 1.36–8.35; p = 0.009) were not overweight or obese based on the BMI CDC range (p = 0.007) and reported using drugs or alcohol at their most recent sexual encounter (OR 2.65; 95% CI 1.04–6.75; p = 0.04), but were significantly associated with having six or more sexual partners in the final adjusted multivariate model (Table 5). No factors were significantly associated with those who reported engaging in sexual intercourse before the age of 17 years.

Table 5.

Factors Associated with Six or More Sexual Partners

	Univariate analyses		Multivariate analyses
	Odds ratio (95% CI)	p	Odds ratio (95% CI)	p
Body mass index (CDC Categorization)
Normal/underweight	Ref
Overweight	0.27 (0.10–0.73)	0.01	0.18 (0.06–0.55)	0.003
Obese	0.51 (0.20–1.33)	0.17	0.40 (0.14–1.14)	0.09
Disclosed HIV status to romantic and/or sexual partner
No	Ref
Yes	2.83 (1.23–6.50)	0.01	3.37 (1.36–8.35)	0.009
Used drugs or alcohol at most recent sexual encounter
No	Ref
Yes	2.49 (1.11–5.57)	0.03	2.65 (1.04–6.75)	0.04
Used condoms at most recent sexual encounter
No	Ref
Yes	0.39 (0.16–0.93)	0.03
Gender
Male	Ref
Female	0.42 (0.19–0.97)	0.04
Belief that ARV medications caused physical changes in body
No	Ref	0.058
Yes	2.29 (0.97–5.39)

Backward selection analysis eliminated condom use, gender, and ARV body changes at p < 0.10 level from the final model shown.

Discussion

Consistent with previous literature,² these findings suggest that body image perceptions among YLWH may influence HIV transmission risk behaviors. Specifically, youth with positive feelings about their overall appearance and contentment with most areas of their body were more likely to report using a condom at their last sexual encounter. Previous literature in this area has primarily focused on adults with HIV limiting the examination of the relationship between body image and risk behaviors among YLWH. Thus, the current study adds to the literature by providing data for clinicians and researchers about the potential relatedness of body image perceptions and health behaviors in this population.

Results from a recent meta-analysis found an association between high scores of body dissatisfaction and low scores of condom use self-efficacy.¹² While the present study did not examine condom use self-efficacy, our results did find an association between using a condom with the most recent sexual partner and increased satisfaction with overall and specific areas of the body. It is possible that youth with increased body satisfaction are more likely to engage in behaviors to protect their body, such as using a condom.²⁵ As such, it will be important to further investigate the relationship between condom use and body image perception, as a potential component to designing effective interventions to prevent secondary transmission of HIV.

It is interesting to note that participants who indicated that they believed their ARV medications had physically changed their body were more likely to disclose their HIV diagnosis to a romantic or sexual partner. This result is in contrast to previous findings among adults that did not find a relationship between diagnosis disclosure and perceived body changes as a result of ARV therapy.²⁶ One potential reason for our findings could be that perceived physical changes in conjunction with other HIV clinical progression (e.g., low CD4 count) indicators have been found to predict HIV status disclosure.²⁷ Still, the specific relationship between disclosure of HIV status to one's partner and the belief that ARV medication has caused physical changes in the body is unclear. Future research is needed to further investigate and clarify this relationship.

Limitations of this study include its cross-sectional design, which constricted our ability to make causal inferences. However, these results provide data for the development of future evaluations to further explore body image among YLWH. In addition, results from this study have the potential to inform clinical practice by highlighting possible avenues of discussion and intervention with patients when addressing health behaviors related to HIV transmission risk reduction. This study was also conducted at a single clinic site, which may limit its ability to generalize to other geographic regions of the United States. In addition, the demographic composition of our sample also limits the generalizability of the findings. Future research is needed to longitudinally explore patterns of body image perception among a diverse sample of YLWH in relation to health behavior in a broader sample.

The results from the present study have the potential to inform clinical practice and warrant further study. By exploring the relationship between body image perception and HIV transmission risk behaviors, results from this study highlight the importance of addressing psychosocial factors such as body image with the intent of reducing risky sexual behaviors among YLWH. Expanding traditional behavioral risk reduction interventions to include aspects such as body image, and using novel techniques such as providing education and feedback about health status markers using mobile apps, may strengthen their effectiveness at promoting sexual health.²⁸ Given the well-documented relationship between body image and health behavior among adults infected with HIV and the high rate of new adolescent HIV infections in the United States, further exploration among YLWH is needed. Further studies are also needed to evaluate body image and HIV related health behaviors in a larger representative sample, for the development of multi-behavior integrated interventions. In addition, results from this study highlight the importance of assessing and intervening on body image perceptions as opposed to body size or BMI focused interventions as a potential mechanism to impact HIV self-care behaviors. To our knowledge there are no known interventions that address body image perceptions among YLWH; thus, further exploration is warranted and urgently needed.

Footnotes

Acknowledgments

The authors acknowledge the contribution of clinical research assistant, Melissa Shenep, and psychology graduate assistant Courtney Peasant, during the data collection phase of this project. The authors also thank Kirk Knapp for his assistance with data abstraction from electronic patient records.

Author Disclosure Statement

No competing financial interests exist.

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