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

Abstract

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. A cross-sectional study was conducted to recruit HIV-positive MSM in Anhui, China. A total of 184 HIV-positive MSM gave informed consent and completed the interview. Correlates of suicidal ideation were assessed using multivariable logistic regression. Fifty-seven (31%) of HIV-positive MSM had suicidal ideations within six months before the interview. Multivariable analyses showed that learning of their HIV status in the past 12 months (adjusted odds ratio (AOR) = 3.4, 95% CI = 1.6–7.3), perceived HIV stigma (AOR = 2.4, 95% CI = 1.1–5.2), depression symptoms (AOR = 2.6, 95% CI = 1.1–5.9) and anxiety symptoms (AOR = 2.7, 95% CI = 1.2–6.1) were significantly associated with the suicidal ideation among HIV-positive MSM. 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 of 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 AIDS

Introduction

Epidemiological survey showed that the estimated number of people in China who are living with Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) were 780,000 by the end of 2011.¹ The most-at-risk subgroups of HIV infection have shifted from injection drug users and blood product recipients 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 sexual transmission 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 a potential predictor 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, few 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 recipients,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 HIV-positive 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 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 research.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 = yes and 2 = 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 self-esteem, whereas a lower score (<15) indicated lower self-esteem. The Cronbach alpha coefficient was 0.77 for this sample.

Data analysis

EpiData 3.1 (The EpiData Association, Odense, Denmark) software was used for data entry. Data were double-keyed by two investigators. Univariate logistic regression analysis was performed to examine statistically significant associations between predictor variables and suicidal ideation. The variables which were marginally significant with P < 0.10 in the univariate analysis were eligible for entry into the multivariable logistic regression model. A forward stepwise procedure based on the Wald test was used to select significant variables in the multivariate model. A P ≤ 0.05 was considered statistically significant. SPSS version 10.0 (Chicago, IL, USA) was used for data analyses.

Results

Socio-demographic characteristics

A total of 184 HIV-positive MSM met study inclusion criteria and completed the study. The average of age was 31.4 ± 9.2 years and ages ranged from 18 to 62, with 68.4% of the participants being less than 35 years old. Approximately half (52.2%) of participants had at least some college education. Around 48.9% of the participants reported monthly incomes which were lower than 2000 RMB (approximately US$320), 83.2% were employed, 35.5% were living alone and 41.8% had ever been married. The socio-demographic characteristics of 184 participants are summarized in Table 1.

Table 1.

Correlates of socio-demographic and clinical factors and suicidal ideation among HIV-positive MSM.

	Number in study (n, %)	Suicidal ideation (n, %)	Univariate analysis
	Number in study (n, %)	Suicidal ideation (n, %)	OR	95% CI
Age (years)
18–24	47 (25.5)	13 (27.7)	1.0
25–34	79 (42.9)	27 (34.2)	1.4	0.6–3.0
>34	58 (31.5)	17 (29.3)	1.1	0.5–2.6
Education level
High school graduate	88 (47.8)	31 (35.2)	1.0
At least some college	96 (52.2)	26 (27.1)	0.7	0.4–1.3
Monthly income (RMB)
< = 2000	90 (48.9)	32 (35.6)	1.0
>2000	94 (51.1)	25 (26.6)	0.7	0.4–1.2
Employment
Unemployed/retired/students	31 (16.8)	12 (38.7)	1.0
Employed	153 (83.2)	45 (29.4)	0.7	0.3–1.5
Marital status
Ever married	77 (41.8)	28 (36.4)	1.0
Single	107 (58.2)	29 (27.1)	0.7	0.4–1.2
Living with whom
Alone	65 (35.3)	21 (32.3)	1.0
Parents/spouse/children	93 (50.5)	30 (32.3)	1.0	0.5–2.0
Others	26 (14.1)	6 (23.1)	0.6	0.2–1.8
Time since learning of HIV status
Up to 12 months	83 (45.1)	34 (41.0)	2.4	1.2–4.5
More than 12 months	101 (54.9)	23 (22.8)	1.0

OR: unadjusted odds ratio; CI: confidence interval.

Prevalence of suicidal ideation and attempted suicide

Fifty-seven (31%) of HIV-positive MSM had suicidal ideations within six months before the interview. Ten (5.4%) of the HIV-positive MSM had attempted committing suicide within the six months prior to the interview. The rates of suicidal ideations of HIV-positive MSM in different socio-demographic characteristics are presented in Table 1.

Potential risk factors in association with suicidal ideation

For socio-demographic and clinical factors, only their known HIV status in the past 12 months (odds ratio (OR) = 2.4, 95% CI = 1.2–4.5, P < 0.01, Table 1) was significantly associated with suicidal ideation among HIV-positive MSM. Age, education level, monthly income, employment, marital status and living situation were not significantly associated with current suicidal ideation.

Table 2 shows the sexual behaviour characteristics of participants. Among all participants, 62% of men identified themselves as homosexual, 31% identified themselves as bisexual and 7% identified themselves as heterosexual or unsure. Approximately, half (44.6%) of HIV-positive participants in this sample reported having sex with male partners and 15 (8.2%) participants reported having sex with female partners in the past six months. Among all participants, about half (48.4%) of participants in the sample reported having sex with someone and 31.5% of them reported not using condoms consistently in the past six months. No statistically signiﬁcant differences in suicidal ideations were observed among HIV-positive participants with respect to sexual behaviour characteristics in the univariate logistic regression analysis.

Table 2.

Correlates of sexual behaviours and suicidal ideation among HIV-positive MSM.

	Number in study (n, %)	Suicidal ideation (n, %)	Univariate analysis
	Number in study (n, %)	Suicidal ideation (n, %)	OR	95% CI
Sexual orientation
Homosexual	114 (62.0)	35 (30.7)	1.0
Bisexual	57 (31.0)	18 (31.6)	1.0	0.5–2.0
Heterosexual/undecided	13 (7.0)	4 (30.8)	1.0	0.3–3.5
Sex with men (in past 6 months)
No	102 (55.4)	32 (31.4)	1.0
Yes	82 (44.6)	25 (30.5)	1.0	0.5–1.8
Sex with women (in past 6 months)
No	169 (91.8)	52 (30.8)	1.0
Yes	15 (8.2)	5 (33.3)	1.1	0.4–3.5
Had sex with anyone (in past 6 months)
No	95 (51.6)	30 (31.6)	1.0
Yes	89 (48.4)	27 (30.4)	0.9	0.5–1.8
Sex with a casual partner (in past 6 months)
No	152 (82.6)	48 (31.6)	1.0
Yes	32 (17.4)	9 (28.1)	0.8	0.4–2.0
Paid money for sex (in past 6 months)
No	180 (97.8)	56 (31.1)	1.0
Yes	4 (2.2)	1 (25.0)	0.7	0.1–7.3
Consistent condom use (in past 6 months, n = 89)
No	28 (31.5)	10 (35.7)	1.0
Yes	61 (68.5)	17 (27.9)	0.7	0.3–1.8

OR: unadjusted odds ratio; CI: confidence interval.

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 = 3.0, 95% CI = 1.5–5.8, P < 0.01), with higher levels of depression symptoms (OR = 4.7, 95% CI = 2.4–9.2, P < 0.01), anxiety symptoms (OR = 4.2, 95% CI = 2.2–8.2, P < 0.01) and low levels of self-esteem (OR = 3.4; 95% CI = 1.4–8.1, P < 0.01) were at increased risk of reporting the current suicidal ideation.

Table 3.

Correlates of psychological factors and suicidal ideation among HIV-positive MSM.

	Number in study (n, %)	Suicidal ideation (n, %)	Univariate analysis
	Number in study (n, %)	Suicidal ideation (n, %)	OR	95% CI
Perceived HIV stigma
None/moderate	125 (67.9)	29 (23.2)	1.0
Severe (>75 percentile)	59 (32.1)	28 (47.5)	3.0	1.5–5.8
Depression symptoms
No	105 (57.1)	18 (17.1)	1.0
Yes	79 (42.9)	38 (48.1)	4.7	2.4–9.2
Anxiety symptoms
No	125 (67.9)	26 (20.8)	1.0
Yes	59 (32.1)	31 (52.5)	4.2	2.2–8.2
Self-esteem
Low	25 (13.6)	14 (56.0)	3.4	1.4–8.1
Normal/high	159 (86.4)	43 (27.0)	1.0

OR: unadjusted odds ratio; CI: confidence interval.

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

Table 4.

Final multivariate model of risk factors for suicidal ideation among HIV-positive MSM.

	Multivariate analysis
	AOR	95% CI
Time since learning of HIV status
Up to 12 months	3.4	1.6–7.3
More than 12 months	1.0
Perceived HIV stigma
None/Moderate	1.0
Severe (>75 percentile)	2.4	1.1–5.2
Depression symptoms
No	1.0
Yes	2.6	1.1–5.9
Anxiety symptoms
No	1.0
Yes	2.7	1.2–6.1

AOR: adjusted odds ratio; CI: confidence interval.

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%, 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 HIV-positive MSM in China.

The results from the present study indicated that there was an increased risk of suicidal ideation among those who learned of their 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, in the early stages of coping with an HIV diagnosis, suicidal 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, 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 psychological 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

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. Thus further research conducted across broader areas of China is warranted. Third, using an interviewer-administered questionnaire might increase the risk of the social desirability bias. 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/AIDS-related stigma and teaching stress management such as general suicide education should be included in health education or intervention programmes among this subgroup population.

Footnotes

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.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the Global Fund to Fight AIDS in China Programs 2012.

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