Happy People, Safer Sex

HIV-Positive Men More Likely to Have Safe Sex When Their Mood Improves; Depressive Episodes Drive Up Risk

February 3, 2014

Having a good week? It may lead to healthier choices. If you are a man with HIV, you may be more likely to use a condom during sex. In a new study, researchers at Columbia University’s Mailman School of Public Health report that HIV-positive men whose moods improved in a given week were more likely to have safe sex than they would in a normal week. In weeks where moods were worse than usual, they were more likely to have unprotected sex.

Results appear online in the journal Health Psychology.

The Mailman School researchers are the first to look at sexual risk as it relates to changes in mood, rather than general level of depression. Over six weeks, 106 sexually active, HIV-positive men who have sex with men living in New York completed weekly surveys that asked about their sexual behavior, depression, and wellbeing during the prior week. Overall, 66% of study participants reported having unprotected anal intercourse in the prior two months; 81% had multiple partners. 

Three-quarters of the study participants were black and Latino men, a group disproportionately affected by HIV. According to the Centers for Disease Control, a quarter of all new HIV infections in the country are in black and Latino men, and 45% in New York City. While the rate of new HIV infections has plateaued overall, for black and Latino men who have sex with men, HIV infections are on the rise.

Healthier choices could make a huge difference. “There is real concern about high rates of unprotected sex happening among gay men, which may be driving increases in the rate of HIV infection,” says first author Patrick A. Wilson, PhD, associate professor of Sociomedical Sciences at the Mailman School. “For this reason, it’s urgent that we understand what drives sexual risk behavior in vulnerable groups so we can find ways to minimize it.”

The researchers found that the men they surveyed who reported an increase in their wellbeing in a given week were more likely to have safe sex (66%), compared to a normal week (46%). The inverse also held true: those who reported higher-than-usual levels of depression were more likely to engage in the risk behaviors (69%).

Previous studies found that depression and emotional wellbeing had little effect on sexual risk-taking, and may even have reduced risk (one explanation was that depression sapped energy for sexual risk-taking). The new study suggests that changes in mood matter more than typical emotional state. “We all have bad days and good days, and bad weeks and good weeks. That’s life. But it turns out that how moods change can be a big factor in influencing condom use,” says Dr. Wilson.

It’s not yet known if there is a common theme to what made the men feel better or depressed. One reason may be everyday uplifts and hassles. But more severe social stressors and economic hardships may also impact the wellbeing in this group. For example, being stigmatized by a family member or stressed from not being able to pay the rent may lead to depression (men in the survey were on the lower end of the income spectrum).

Another unanswered question: How exactly do moods lead to healthy or unhealthy choices? Maybe higher wellbeing buffers against stressors men experience that can lead to a fatalistic outlook in which they throw caution to the wind. On the other hand, says Dr. Wilson, “They might think in bad weeks, ‘I don’t have much of a life to live, anyway. I have to deal with finding food today or a place to stay. HIV is the least of my concerns.’”

“Or maybe they don’t have the power to negotiate safe sex for themselves,” adds co-author Gertraud Stadler, PhD, associate research scientist in Sociomedical Sciences at the Mailman School. “When you’re depressed you’re less able to stand up for yourself.”

The arrow might also point the other direction: Unprotected sex could lead to feeling depressed. However, other studies have suggested that negative feelings like guilt after unprotected sex are rare.  “Mostly our participants described these sexual encounters as positive,” notes Dr. Wilson.

Designing an intervention to fit with the study’s findings may prove difficult. “We’ve learned that there isn’t a high-risk group of depressed people that we can easily identify and treat,” says Dr. Stadler. “Instead we have to intervene when they are feeling worse than usual since that’s when the risk occurs.” One futuristic intervention she envisions might resemble the movie “Her,” where a smart phone is able to pick up on depression by changes in vocal intonation or textual cues.

Another approach would be to teach the men how to maintain wellbeing. “It boils down to coping—recognizing your emotions and how to respond when they change,” says Dr. Wilson, adding that the group’s socioeconomic status also plays in. People are often able to regulate their emotions because they have stable jobs, housing, and support networks, he says. “A structural intervention is needed to address the adverse conditions these men are in.”

Could the findings apply more broadly with all gay and straight couples? More studies are needed, but “the idea of sexual risk influenced by fluctuations in mood is likely consistent across groups,” says Dr. Wilson. Economic theory may provide a clue, adds Dr. Stadler. “Daniel Kahneman and Amos Tversky won the Nobel Prize for their work showing that when a person experiences loss—something akin to worsened mood—they are more likely to take risks. Likewise, when people feel they have gained something, they are less likely to take risks.”

Co-authors include Melissa R. Boone, a doctoral student at the Mailman School, and Niall Bolger, professor of Psychology at Columbia University.

Funding for the study was provided by the Center for Interdisciplinary Research on AIDS at Yale University through the National Institute of Mental Health (P30MH62294) and by a development grant from the Office of the Vice Provost for Diversity Issues, Columbia University.