1) The document examines the relationship between mental health and HIV/AIDS risk behavior in Asia. It finds that mental health problems like depression, anxiety, alcohol dependence, and substance abuse can increase risky behaviors and HIV transmission. 2) Intervention programs integrating mental health treatment have been shown to reduce HIV risk behaviors in other areas of the world. The document argues for expanding such programs in Asian countries with high HIV rates. 3) Specifically, it recommends prioritizing mental health interventions for HIV prevention in South and Southeast Asia, where HIV prevalence is highest and such programs are less established.

1. Mental Health and HIV Risk
Prevention in Asian countries
Jaeha Kim
Seoul International School

2. ABSTRACT
The objective of this study was to examine the empirical evidence in support of the
relationship between mental health and HIV/AIDS risk behavior in a global as well as the
regional context of Asia. Through this research we aimed to suggest areas of research that still
needs to be done in Asia, as well as the types of intervention that could be useful in reducing
risk behavior in Asian countries. Through researching a variety of literatures regarding
HIV/AIDS, I was able to summarize my findings, as well as suggest possible solutions to the
issue of HIV/AIDS risk behavior. The results in detail are written below, but to summarize,
there is a sufficient amount of existing evidence to support the claim that mental health
problems are a predictor of HIV/AIDS risk behavior. Not only do non-affective psychosis,
depression, and anxiety affect risk behavior, alcohol dependence syndrome as well as
substance use can have a big effect in amplifying HIV/AIDS risk behavior amongst adolescents
as well as adults. A variety of nations have already adopted mental health programs in order to
combat HIV/AIDS risk behavior, and the effort needs to be continued in many Asian countries
that have not done so. In terms of cost and the effectiveness of the approach, mental health
intervention of HIV/AIDS risk behavior must start in targeted Asian countries where HIV
incidence is higher, especially in South and Southeastern Asia.

3. INTRODUCTION: Current State of HIV/AIDS
Since the 1990’s, HIV/AIDS has been a serious problem in the global arena. Cited for its
global and domestic impact, the infectious disease has been getting worse by the day until most
recent years. While the World Health Organization’s Global Programme on AIDS predicted that
a cumulative number of 40 million people worldwide would have been infected by HIV/AIDS by
2000, the actual turnout was much greater [30]. With 56 million people cumulatively infected by
HIV/AIDS in 2000, the Joint United Nations Programme on HIV/AIDS (UNAIDS) officially stated
that HIV/AIDS constitutes one of the most serious issues facing human development in the 21st
century [31].
The impacts of HIV/AIDS infection in the various countries are devastating to say the least.
From age 59 to 45, HIV/AIDS in Sub-Saharan Africa has significantly lowered life expectancy
amongst countries in the region. The lowering of life expectancy as well as the increased
number of patients in the workforce have contributed to economic failure, as studies have
shown that HIV prevalence and severity of reduction in Gross Domestic Product (GDP) are
correlated (Fig. 1). In addition, high prevalence of the disease has led to severe damage within
numerous households, limiting access to proper healthcare, food, and education [32].
1) HIV/AIDS in the global context

4. INTRODUCTION: Current State of HIV/AIDS
Similar to other infectious diseases, the proportion of HIV/AIDS infection in poorer, less
developed countries is growing rapidly, especially in the European region. In order to combat
the disease, the effects of behavioral change on HIV risk behavior, especially amongst younger
populations has been successfully studied now. For example, in Senegal, infection rates
consistently remained below 2 per cent, demonstrating the success of a nationwide campaign
to modify sexual behavior [1].
Figure 1. Relationship between HIV/AIDS prevalence and Gross Domestic Product in various countries. Figure from ref. 1
1) HIV/AIDS in the global context

5. INTRODUCTION: Current State of HIV/AIDS
The distribution of HIV/AIDS prevalence and incidence differs based on region. Within
the Asian continent, there is a great amount of variation between smaller regions of Asia.
While HIV/AIDS in South and Southeast Asia displays a 0.56% prevalence rate, HIV/AIDS
in East Asia and the Pacific is under better control, with only 640,000 people, or 0.07%the
region’s adult population, with the disease. While Thailand and several other countries of
South Asia have demonstrated resilience in combatting the disease through various risk
intervention methods [2], the recent downfall in public health investments bring to
question the sustainability of these developments.
While other risk-interventions have been studied, the psychiatric aspects of HIV-risk
behavior have become of great interest amongst HIV/AIDS social researchers. Previous
studies have demonstrated that HIV/AIDS diagnosis predicts a 40% depression rate and
36% anxiety rate; recent studies have indicated that these psychiatric disorders amongst
others may also influence HIV-risk behaviors [33]. Mental health interventions have been
shown to work in numerous studies, and the need to expand on these treatments in
addition to pre-existing campaigns on safe sex, and sanitary needle usage should be
emphasized in Asia.
2) HIV/AIDS in the Asian region

6. HIV/AIDS and mental health shares a rather complicated relationship. As one of the
previous authors have stated [4], it is a bidirectional relationship, as there is evidence
both that HIV/AIDS diagnosis can affect mental health, and that mental health illnesses
often contribute to transmittance of HIV/AIDS amongst various populations by
influencing individuals’ risk behaviors. In a study conducted in the USA as well as in
Europe, the infection rate amongst those with mental illnesses ranged from 4 per cent
to 23 percent [5,6], much higher rates when compared to the infection rate of the
general population. In a study conducted in India, the seroprevalence ratio amongst
psychiatric inpatients with high risk behavior was 2.11 percent [7]. Amongst the
seropositive psychiatric inpatients, there were a variety of mental illnesses. Forty-four
percent of the patients had Alcohol Dependence Syndrome, 14 per cent had non-
affective psychosis such as schizophrenia or drug induced psychosis, 14 per cent had
depression, and 9.3 per cent had bipolar affective disorders.
Mental Health effects of HIV Risk Behavior

7. Because of the fact that there are many types of mental illnesses that could
potentially relate to or influence HIV/AIDS risk behavior, and because of the
complicated nature and interaction of the illnesses, the following sections are intended
to categorize the psychiatric disorders into three groups: 1) Alcohol Dependence
Syndrome and Substance Drug Abuse, 2) Depression, Anxiety, and Trauma-related
mental illnesses, and 3) Non-affective Psychosis. These sections will review the
literature, which provides evidence in support of the hypothesis that mental illnesses
can impair judgment, leading to an increase in risk behaviors that increase the likelihood
of transmittance of HIV/AIDS.
Across mental illness type, it is worth noting that high-risk sexual behaviors differ by
gender. Most men displayed HIV/AIDS risk behavior through unprotected heterosexual
sex, intercourse with commercial sex worker, and most importantly multiple sexual
interactions. Women commonly displayed risk behavior through unprotected sex with
high risk partners. The study was also able to determine that amongst those with
psychiatric disorders, men were more likely to report high-risk behavior [8].
Mental Health effects of HIV Risk Behavior

8. Among the seropositive patients in the study in India described above [7], 44 per cent
had only alcohol dependence syndrome. When those with alcohol dependence syndrome
and other psychiatric diseases were included, the percentage increased to 69.7 per cent.
This demonstrates that alcohol dependence is in fact one of the most common mental or
psychological disorders affecting HIV risk behavior.
To further understand the relationship between alcohol dependence and HIV risk, a
study was conducted in South India with a larger sample of psychiatric inpatients [9]. The
findings of the study found that indeed alcohol dependence correlated with sexual risk
behavior. Men who had sex, used tobacco, had an Alcohol Use Disorder Identification Test
(AUDIT) score above 8, and had a Drug Abuse Screening Test (DAST) score above 2
showed higher likelihood of displaying sexually risky behavior.
1) Alcohol Dependence and Substance Abuse
Mental Health effects of HIV Risk Behavior

9. Mental Health effects of HIV Risk Behavior
Despite the fact that intravenous drug use was not too common in the region of this study
(Bangalore), evidence exists from various other studies that substance use of other kinds is
consistently associated with risky sexual behavior. A study conducted in India confirmed that
amongst 352 men with substance use-related disorders, approximately 13 per cent engaged in
high-risk sexual behaviors [10]. This may be due to the role of personality factors (e.g.,
impulsivity), to impaired judgment caused by the effect of substances on cognitive ability, or to
situational influences of substance use on sexual interaction (e.g., exchanging sex for drugs) that
leads to unsafe sexual behavior [11,12,22]. Studies have confirmed that treatment of drug
addiction and substance use can reduce sexual risk behavior among the mentally ill [13].
1) Alcohol Dependence and Substance Abuse
Figure 2. Relationship and pathway of sensation seeking, drug use, alcohol use and unprotected anal intercourse
(a form of highly risky HIV/AIDS behavior). Figure from ref. 26.

10. Depression, anxiety, and trauma-related mental illnesses are some of the most
common mental/emotional disorders among adolescents and adults alike. It is
therefore extremely important to understand the extent to which they predict
HIV/AIDS high-risk behavior. Often these disorders, too, lead to cognitive deficits,
problems with risk assessment, and poor impulse control, which in turn increase the
likelihood of engaging in substance abuse accompanied by needle sharing and/or
engagement with multiple sex partners [17,18]. In fact, depression, anxiety, and
trauma-related illnesses were shown to increase rates of drug use (odds ratio
OR=17.2) and also higher rates of alcohol dependency (OR=8) [19] in a study done in
the US. However, in addition to the HIV/AIDS risk behavior that can be exacerbated
or increased by substance abuse and alcohol, depression and anxiety can also
influence such HIV/AIDS risk behavior, independent from substance use.
2) Depression, Anxiety, and Trauma-related Mental Illnesses
Mental Health effects of HIV Risk Behavior

11. One of the major consequences of depression is a lack of self-esteem and assertiveness
[18].This can play a big role in increasing the HIV/AIDS risk behavior in mentally ill patients
[18]. Due to the lack of assertiveness, numerous studies (most of which were conducted in the
United States) cite that consistently implementing safe sex practices may be difficult for these
patients [18]. Also, depression may lead to destructive risk-taking behavior, especially among
adolescents. Blatt et al. found that many adolescents who did not meet the requirements to be
hospitalized for anxiety or depression often ended up expressing self-destructive behavior [20].
The study found that such destructive behavior could manifest itself in sexual promiscuity,
multiple sex partners, or IV drug use. Confirming these findings, Orr et al. found that in two
urban health centers in Baltimore, depressed patients (173 African American women in this
case) were more likely to report multiple partners (OR=1.7), IV drug use (OR=4.5), or having a
partner who they knew already had an STD (OR=2.4) [21]. Amongst adolescents in the US,
depression induced a 5.6-fold increase in the likelihood of participating in prostitution, and an
increase in IV drug use (Anxiety: OR=11.7; Post-traumatic stress disorder; OR=5.9) [22].
2) Depression, Anxiety, and Trauma-related Mental Illnesses
Mental Health effects of HIV Risk Behavior

12. In a case study by Frances et al, it was also found that depression might possibly lead to a
unconscious desire to contract the HIV/AIDS disease. This is due to the fact that depression often
provokes suicidal thoughts. With chronic suicidal thoughts and depression, an increase in HIV/AIDS
risk behavior has been suggested as an unconscious effort to seek a method of suicide [23].
Interestingly, however, new studies have suggested that depending on the type and intensity of
depression, the degree of sexual risk-taking behavior may differ [25]. Those with signs of extreme or
severe depression displayed signs of loss of sexual desires, while those with moderate depression
had high levels of sexual risk-taking in accordance to the findings of previous studies. Clearly, more
research needs to be done to fully understand the effects of depression on sexual risk-taking
behavior.
In a study of 146 female hospital inpatients, 30 per cent of the women revealed that they had been
either sexually abused as a child, as an adult, or at both time periods. When these women were
studied, it was revealed that a history of sexual coercion was correlated to high sexual risk behavior,
with more severe coercion being related to higher prevalence of HIV risk behavior. According to
Chandra et al., [7] poor negotiation skills and lack of control of sexuality are specific factors that
contribute to sexual risk behavior and are associated with a history of sexual abuse and trauma.
2) Depression, Anxiety, and Trauma-related Mental Illnesses
Mental Health effects of HIV Risk Behavior

13. In a study done in India, high-risk behavior for HIV/AIDS contraction was found in 59% of
patients with non-affective psychosis, more specifically schizophrenia. From a variety of
other studies, the cause of such high risk was determined to be a combination of many
factors. As those with schizophrenia, as well as other nonaffective psychosis, often were
exposed to low quality environments, their exposure to IV drug use, alcohol abuse, as well as
prevalent contact with high-risk populations led to their vulnerability to display high levels of
HIV/AIDS risk behavior [27]. In addition, their naiveté and negligence in dealing with personal
safety and health further amplified their contraction of the disease.
While it was traditionally thought that schizophrenia would lead to a decrease in sexual
desire due to the psychiatric drugs used to treat the disorder [28], the introduction of
neuroleptic drugs has dynamically changed this phenomenon. Most patients with
schizophrenia reported a desire for an active sexual life, which many of them were already
experiencing. In a study of these processes, researchers determined that 83 percent of the
male and female adult patients demonstrated high-risk behaviors during sexual intercourse
[28].
3) More Severe Mental Illnesses
Mental Health effects of HIV Risk Behavior

14. The cause of these high-risk behaviors was mostly due to a lack of proper information that
these individuals had about HIV/AIDS. It was determined that women with schizophrenia
incorrectly answered numerous questions regarding HIV/AIDS [28]. With misconceptions
that HIV/AIDS could not be passed through if one only had sex with men, or that those with
HIV/AIDS always look sick, these mentally ill patients were even more uneducated about the
disease than the general population [28]. In order to counter these false beliefs held by this
population, governments have distributed a series of advertisements and implemented
educational programs.
However, such efforts have not yet surpassed the mental barrier than schizophrenia
patients have in terms of cognitive deficits which impact their ability to learn new
information effectively [29]. In sum, populations afflicted with such nonaffective psychotic
disorders are extremely vulnerable to HIV transmission through not only a high likelihood of
engaging in risk behaviors, but also through a lack of correct information and understanding
about how to make safer choices.
3) More Severe Mental Illnesses
Mental Health effects of HIV Risk Behavior

15. DISCUSSION: Previous mental health
intervention efforts
There have been many mental health intervention efforts that have been conducted in the
western hemisphere, but not necessarily in the Asian region. Early adoption of these efforts
have been favored in the west due to the fact that preventing HIV risk behavior through
mental treatment is much more cost-effective than treating mental behavior caused by HIV
diagnosis [16]. Some mental health interventions that have been successful in the west
should be of primary interest for those attempting to adopt these in Asian regions.
A mental health intervention that helped in significantly reducing the HIV risk behavior of
those with severe and chronic mental illness problems was done in the US by Weindhart et
al (1998) [34]. Because those with severe mental illnesses often had problems in being more
sexually assertive, researchers tested the effect of “increased assertiveness” on women
who were trained through ten sessions of “assertiveness training intervention”. Research
found that amongst the twenty female outpatients of the study, there was an increase in
knowledge regarding HIV/AIDS, an increase in the frequency of condom use during sexual
intercourse, and most importantly an increase in their skills to assert themselves [34]. Such
interventions were explicitly stated to be a possible step one in creating a risk-intervention
program for those with HIV/AIDS.

16. DISCUSSION: Previous mental health
intervention efforts
Another mental health intervention that succeeded in terms of reducing HIV/AIDS risk
behavior was studied by Sullivan et al (1999) in the US. With increase public investments in
information sessions as well as general awareness regarding the heightened vulnerability of
mentally ill to display HIV/AIDS risk behavior; the government was able to create a decrease
of HIV risk behavior amongst patients themselves [35].
When deciding on the comprehensive and complicated methods of mental health risk-
intervention programs, it is of utmost importance to take into account the culture of the given
area. As stated and emphasized in the number of mental health interventions above, it is also
equally important that people do not feel violated in any way or form. Assertiveness training
interventions as well as a stronger support from public health investments by the government
is predicted to increase the success of HIV risk intervention in a variety of countries ranging
from Cambodia to all over Asia.

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24. Thank you !