Sex, Drugs, and Depression: The Synergy of Concurrent Health Conditions and the Need for Whole-Patient Care
Lots of studies looking at HIV transmission have focused on condom use and the factors associated with reduced condom use. However, as the risks for HIV have evolved, new outcomes have taken center stage. So-called, "seroadaptive strategies" are now highly prevalent in the gay community and are used by gay and bisexual men to prevent HIV acquisition and transmission. Because of these strategies, condom use is no longer the best indicator of HIV risk. In fact, the Momentum Health Study finds that condom use is not associated with seroconversion. Instead, new cases of HIV are predicted by condomless anal sex with partners who have a different or unknown HIV status.
Examining what factors are associated with this new outcome is important, which is why a recent analysis by the Momentum Health Study looked at whether depression and substance use were associated with "serodiscordant or unknown condomless anal sex." Both of these factors have often been identified as predictors of condom use, so it is natural to assume that they might also play a role in this new outcome. For instance, you can imagine that if your high, you might forget to ask someone's status. Or if you're depressed, you might not have the self-concern to even care.
So, in examining these relationships, here's what we found: only at the highest levels of depression and substance use were men at increased risk to engage in condomless anal sex with serodiscordant or unknown status partners. While this is somewhat good news (i.e., having poor mental health or using drugs alone are not driving HIV transmission), it also highlights the existence of a core group of vulnerable men whose drug use and mental health may be impacting their ability or desire to prevent HIV.
There are obviously lots of ways to take these findings, but for me they highlight the need for better screening to identify concurrent patterns of substance use and mental health conditions. This is particularly so given our observation that individuals who have multiple concurrent health problems are more likely to engage in behaviours which might put themselves or their partners at risk for HIV. Therefore, identifying those individuals with the greatest need, perhaps through the use of a clinical screener or through one-on-one conversations, is the first step to providing integrative patient-centered prevention and care. Once needs are clearly identified and appropriately assessed, our hope would be that specific steps can be taken to help these individuals cope with and manage their mental, physical, and sexual health. For instance, doctors specializing in mental health and substance use should familiarize themselves with the prescription guidelines for HIV-prevention strategies such as "Treatment as Prevention" (TasP) and "Pre-Exposure Prophylaxis" (PrEP) -- which can be used to eliminate HIV transmission and acquisition among at-risk individuals. By integrating these and other preventative sexual health measures into routine care, we can better help those who might not be accessing these services through traditional sexual health clinics -- allowing us to "cast our net wide", so to speak.
Of course, many clinicians are not necessarily comfortable managing the many and varied health conditions of their patients -- especially given the broad spectrum of conditions that their patients may face. While this partially speaks to the need for medical schools and continuing education departments to integrate mental, substance use, and sexual health training into their curricula, we know that "this is not the panacea we are looking for." Concurrently, clinicians need to identify integrative services offered in their region to which they can refer their patients who exceed their capacity to treat. To assist them, public health departments should develop referral guidelines that balance the need for integrative care against the availability of these services. If such a balance is not easily achieved, more services should be provided or incentivized. This is how we achieve patient-centered care, by treating people as whole people not just as people with depression, or people who have sex, or people who use drugs. Whole people. My hope would be that changes such as those outlined above, might ultimately make it easier for people to access the care they need.