- Email: [email protected]
AIDS Risk-Behavior Knowledge in Schizophrenia
Negative Symptoms and HIV/AIDS Risk-Behavior Knowledge in Schizophrenia LIEZL KOEN, MBCHB, MMED(PSYCH), SUSAN UYS, MBCHB DANA J.H. NIEHAUS, MBCHB, MMED(PSYCH), DMED, ROBIN A. EMSLEY, MBCHB, MMED(PSYCH), PH.D.
Schizophrenia sufferers have been demonstrated to have relatively poor HIV/AIDS risk-behavior knowledge and, as a group, are found to be particularly vulnerable to contracting HIV. The authors asked whether an association could be demonstrated between specific symptoms and differing levels of knowledge. A structured clinical interview and HIV/AIDS Risk Questionnaires were administered to 102 subjects, and a principal-component analysis was performed for global and individual items, followed by comparisons between factors. Three factors (negative, positive, and global thought-disorder) emerged as significant between poor HIV/AIDS risk-behavior knowledge and higher negative-symptom scores. Findings support the notion that existing educational programs should be adapted to target specific areas of deficit. (Psychosomatics 2007; 48:128–134)
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outh Africa is home to 46 million people, of which 5.3 million are estimated to be HIV-positive, representing a total population prevalence rate of 11%—one of the highest in the world.1 Studies have indicated that people living with a serious mental illness are particularly vulnerable to contracting HIV.2,3 Reported rates of infection in mentally ill patients range from 3.1% to 22% (no South African data exist), in comparison to reported ranges of between 0.6% and 11% in the general population.4–6 The popular misconception that severely mentally ill persons lack the skills to form intimate relationships or have less need to do so led to the underestimation of the risk of HIV infection in this population during the first decade of the AIDS epidemic.7 Even now, many contemporary mental-health policy reports fail to discuss the risk Received December 21, 2005; revised March 13, 2006; accepted March 20, 2006. From the Ngaphakathi Workgroup, Dept. of Psychiatry, Univ. of Stellenbosch, Cape Town, South Africa. Send correspondence and reprint requests to Dr. Liezl Koen, P.O. Box 19063, Tygerberg 7505 South Africa. e-mail: [email protected] Copyright 䉷 2007 The Academy of Psychosomatic Medicine
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of HIV/AIDS in people with severe mental illness, and there are few specific references to sexual-health promotion in these documents.8 In fact, studies examining high-risk sexual behaviors among adults with severe mental illness have indicated that not only do they often engage in such behaviors (e.g., unprotected intercourse, multiple partners, sex trade, and intravenous drug use),9,10 but they also underestimate the risk of infection.11,12 They report little fear of contracting HIV,13,14 with their perception of personal risk of infection ranging from none to low.15 Furthermore, comparative studies have revealed that people with severe mental illness (and specifically those with a diagnosis of schizophrenia)16 exhibit lower levels of HIV/AIDS risk-behavior knowledge than is found in the general population.9,17 It is well known that a wide spectrum of clinical presentations are exhibited in schizophrenia. Therefore, rather than just accept that it is mainly a lack of information or inaccurate information about HIV infection that contributes to the poor levels of HIV/AIDS risk-behavior knowlPsychosomatics 48:2, March-April 2007
Koen et al. edge in patients with schizophrenia,18 we may find that clinical factors such as poor reality-perception, affective instability, formal thought disorder, and impulsivity may be even more important causes of this relatively poor knowledge level. Although a number of studies worldwide have examined levels of HIV/AIDS risk-behavior knowledge in patients with schizophrenia,13,16,19 a paucity of data exist on whether specific symptoms or symptom clusters contribute to the differing levels of HIV knowledge (or lack thereof) within specific schizophrenia populations. Factor analysis is one of the methods that could be used to determine symptom structure by utilizing the data collected with measures that have been specifically developed to explore the relationships between the various symptoms of schizophrenia. In a practical application of this technique in psychiatric illness, Emsley et al.20 investigated the factor structure of both the global and individual items of the Schedule for the Assessment of Negative Symptoms (SANS)21 and the Schedule for the Assessment of Positive Symptoms (SAPS)22 in a large sample of South African Xhosa patients with schizophrenia. Their analysis (principalcomponent analysis [PCA] with varimax rotation; eigenvalues ⬎1) yielded a two-factor solution representing positive and negative symptoms, which accounted for 59.9% of the variance. Analysis of global ratings also revealed a five-factor model (less strict eigenvalue criteria, accounting for 85% of the variance) that was consistent with previous studies, where the first two factors were the same as those of the two-factor analysis (negative and positive dimensions), and the other three consisted of attentional impairment, alogia, and a disorganizational factor. By producing findings that were very similar to that of studies done in other parts of the world, the authors provided evidence supporting the notion that the factor structure for the symptoms of schizophrenia is relatively resistant to cultural influences. This five-factor model provides a theoretical framework in which specific symptom domains can be identified and then assessed for their influence on specific variables, such as the level of knowledge of HIV risk-behaviors in patients with schizophrenia. Indeed, if such an association could be demonstrated, healthcare workers could utilize clinical presentation to identify individuals likely to have poor knowledge. Our study therefore aimed to identify whether specific symptom domains could be shown to be associated with differing levels of HIV/AIDS risk-behavior knowledge in schizophrenia patients. Psychosomatics 48:2, March-April 2007
METHOD Subjects and Assessments Patients were recruited from the Stikland Psychiatric Hospital Catchment area (Cape Town, South Africa) as part of a larger, ongoing genetic study. The group consisted of 102 Xhosa patients with a diagnosis of schizophrenia,23 who were at various stages of illness at the time of the interview. The Xhosa are one of the indigenous populations of South Africa and form part of the Nguni-language group. Adult patients (age 18–65 years), both men and women, were included. Each participant was interviewed by a clinician, who administered a standardized interview (the Diagnostic Interview for Genetic Studies [DIGS] Version 2.0)24 in English, Afrikaans, and/or Xhosa (with the help of an interpreter). The DIGS includes the SANS and the SAPS. The interviewers used hospital and clinic chart records (where available) and information gathered from family members to complete these interviews. A urinary drug screen was also performed on all participants. The AIDS Risk-Behavior Assessment Questionnaire (ARBAQ; Table 1) and the AIDS Risk-Behavior Knowledge Questionnaire (ARBKQ;13 Table 2) were also administered by a clinician. Also, individuals were asked whether they believed that AIDS could be transmitted via their depot antipsychotic injection. The ARBAQ is a tool used by researchers to determine to what extent participants encounter or participate in potentially high-risk sexual behaviors. The scale used was adapted from a similar scale25,26 by the MRC Unit on Anxiety Disorders, affiliated with the Department of Psychiatry, University of Stellenbosch, South Africa. The ARBKQ is an 11-item True/False questionnaire that assesses an individual’s knowledge about the cause and potential transmission of HIV/AIDS. The items used are believed to be those most pertinent to assess knowledge in this population and were adapted by the original author from a previously normed and validated 40-item scale.25 The study was approved by the committee for Human Research of the University of Stellenbosch, and their ethical guidelines were strictly adhered to at all times. Statistical Analysis A principal-component analysis (PCA) with varimax rotation and eigenvalues ⬎1 was performed on the participating group for the nine global ratings and on the individual items of the SANS and SAPS. The global scores of each of the item groups (affective changes, alogia, http://psy.psychiatryonline.org
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HIV/AIDS Risk-Behavior in Schizophrenia avolition/apathy, anhedonia, hallucinations, delusions, thought-disorder, and behavioral changes) were summed in line with factor-structure findings (e.g., the negativesymptom factor score comprised global scores of affective changes, alogia, avolition/apathy, and anhedonia. Next, the total number of correct responses was calculated for the ARBKQ, and we compiled descriptive statistics, calculating the mean, median, and mode, and the sample was then dichotomized around the median (taking into consideration the mean and mode). On the basis of this method, we dichotomized the level of knowledge into High score (⬎7) and Low score (ⱕ7). Student t-tests were then used to compare the High- and Low-scoring groups in terms of the nine global items on the SANS and SAPS, to the individual items of the SANS and the symptom factors identified earlier. Subsequently, the negative-symptom domain was dichotomized around the median (score: 9), and chi-square or Student t-tests were used to determine whether any sigTABLE 1.
nificant association existed between the level of negative symptoms and number of sex partners, number of sexual encounters, and condom use. RESULTS Demographics Our sample comprised 102 Xhosa schizophrenia patients (76 men, 26 women), with a mean age of 32.28 (standard deviation [SD] 9.66) years. The majority of the patients were single (N⳱79); 10 were married, 6 were divorced, 5 were separated, and 2 were widowed. Nearly half (N⳱50) were unemployed; 45 were receiving a disability grant, and only 7 had regular employment. In all, 70 participants had a regular partner or spouse at the time of the interview, and 44 had had sex in the last 6 months. The majority of the patients (N⳱75) had not used a condom the last time they had had sex. Most
HIV/AIDS Risk-Behaviour Assessment Questionnaire Yes
1 2 3 4 4.1 4.2 4.3 5 6 7 8 9 9.1 9.2 9.3 9.4 10
Do you currently have a partner/spouse? Have you had sex in the last 6 months? Did you use a condom with your last sexual encounter? Have you had sex in exchange for: Money? Drugs? Place to stay? Have you had sex with a partner who used injected drugs? Have you had sex after using alcohol/drugs? Have you had sex with someone you have known for less than 24 hours? Have you been pressured into unwanted sex or been raped? Who was your first sexual partner? A regular partner or spouse Casual partner Rape Other/Unsure Age at time of first sexual encounter, years mean (standard deviation)
TABLE 2.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
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68.6% 43.1% 24.5% 7.8% 1% 5.9% 7.8% 28.4% 32.4% 7.8% 92.2% 4.9% 1% 1.9% 16.9 (2.8)
HIV/AIDS Risk-Behaviour Knowledge Questionnaire
Most people become sick quickly after getting the AIDS virus. Women can’t get AIDS if they only have sex with men. People who can give you the AIDS virus always look sick. Men can’t get AIDS if they only have sex with women. Washing after sex stops AIDS. Only gay (homosexual) men get AIDS. You must have many sex partners to get AIDS. Sex with someone who has used injected drugs creates risk for AIDS. Using condoms (rubbers) can help prevent AIDS. Unborn babies can get AIDS from their mothers. You can get the AIDS virus through one sexual contact.
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Correct Answer
Patients Correct
False False False False False False False True True True True
39.2% 73.5% 48% 66.7% 77.5% 56.9% 52.9% 58.8% 81.4% 80.4% 68.6%
Psychosomatics 48:2, March-April 2007
Koen et al. (N⳱94), reported that their first sexual partner had been their regular partner or spouse; five had their first experience with a casual partner, and one reported having been raped. High-Risk Behaviors With regard to high-risk sexual behaviors, eight patients admitted to having had sex in the past in exchange for money, one for drugs, and six for a place to stay. Only eight had had sex with a partner who used intravenous drugs. Twenty-nine admitted to having had sexual intercourse after using alcohol or drugs, and 33 had had sex with a partner they had known for less than 24 hours. Eight reported that at some stage they had been pressured into unwanted sex or been raped. (See Table 1 for a full summary of results.) Comorbid Substance Abuse Lifetime comorbid alcohol abuse could be documented in 30 participants and cannabis abuse in 47 cases. A total of 67 admitted to abusing either alcohol or cannabis or both on a regular basis. A urinary drug-screen revealed a positive cannabis result in 11 cases. No lifetime or current injection drug abuse was documented in any of the participants. A large majority (N⳱76) were regular tobacco smokers. AIDS Risk-Behavior Knowledge Questionnaire On the ARBKQ, out of a possible score of 11, the mean was 7.05 (SD: 1.77); the median, 7.0; and the mode, 8.0. (See Table 2 for a full summary of the results.) A number of interesting knowledge deficits were revealed. Nearly two-thirds (N⳱60) thought that most people become sick quickly after getting the AIDS virus, and more than half (N⳱53) believed that people who transmit the AIDS virus always look sick. Forty percent (N⳱41) thought that only homosexual men were at risk for contracting AIDS. Nearly one-third (N⳱32) believed that one could not get AIDS through just one sexual contact, and nearly half (N⳱48) believed that one would have to have had many sexual partners to contract AIDS. As to the question of whether AIDS could be transmitted via the depot antipsychotic injection, seven of the participants indicated that they believed this to be true. Principal-Components Analysis (PCA) The results of the PCA revealed three factors with an eigenvalue ⬎1. (See Table 3 for full results.) Together, Psychosomatics 48:2, March-April 2007
these three factors accounted for 66.58% of the variance. The first factor, accounting for 33.78% of the variance, represented the negative-symptom dimension (eigenvalue: 3.04). Global affect, alogia, avolition, and anhedonia loaded high on this factor, whereas behavior loaded only to a lesser extent. The second factor represented the positive-symptom dimension (eigenvalue: 1.83), with hallucinations and delusions loading high. The third factor (eigenvalue: 1.11) largely comprised global thought-disorder. Comparison When assessing the levels of knowledge of HIV riskbehaviors by each of these factors, a statistically significant difference was shown for the negative-symptom factor. A high negative-symptom factor score (SANS ⬎9) was shown to be significantly associated with poorer HIV riskbehavior knowledge (ⱕ7 correct answers; p⳱0.015). No association could be demonstrated between SAPS scores and any of the factors. There was no statistically significant difference between the number of sexual encounters or sexual partners (past 6 months) or other risk behaviors when the Low and High negative-symptom score groups were compared with each other. Looking at the individual items of the SANS, the most significant contributing items to the PCA factors were poor grooming (p⳱0.005), latency (p⳱0.011), thought content (p⳱0.013), lack of intimacy (p⳱0.012), poor eye contact (p⳱0.019), and affective nonresponsiveness (p⳱0.036). Inappropriate affect did not seem to be a statistically significant contributing factor. We must note that the lack-ofintimacy item had a significantly skewed distribution and thus would be difficult to interpret within this data-set. DISCUSSION In keeping with worldwide findings, the results of our study confirmed the presence of high-risk sexual behaviors within the context of the relatively poor HIV/AIDS riskbehavior knowledge in a South African population of schizophrenia patients. The participants could only achieve an average score of 65% (7.01 answers correct) on the AIDS Risk-Behavior Knowledge Questionnaire (ARBKQ) and, compared with a control population (average 81%; 8.99 correct), the schizophrenia group demonstrated significant overall and specific knowledge deficits with regard to HIV/AIDS risk-behavior knowledge.27 Our behavioral findings are not unique to this study http://psy.psychiatryonline.org
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HIV/AIDS Risk-Behavior in Schizophrenia group but merely reflect the universally consistently high rates of HIV/AIDS-related risk-behaviors among adults with severe mental illness, as highlighted by several review articles.2–4,10,28 However, the main aim of our study was to investigate whether differing levels of risk-behavior knowledge within the study group could possibly be associated with the presence of specific clinical symptoms or symptom clusters. Our results showed that a higher score on the negativesymptom domain significantly correlated with poorer knowledge about HIV/AIDS risk-behavior as measured by the ARBKQ (⬍7 correct responses). Furthermore, the individual items in the negative-symptom domain, that is, poor grooming, speech latency, poor thought content, poor eye contact, and affective nonresponsiveness, were also demonstrated to be significantly associated with poorer risk-behavior knowledge. A literature search revealed only one previous study that specifically attempted to look at correlations between psychiatric symptoms and levels of HIV/AIDS knowledge. McKinnon et al.26 interviewed 178 psychiatric patients (various diagnoses) and also completed a Positive and Negative Syndrome Scale29 for each. These scores were then used to demonstrate that a significant relationship existed between poorer HIV/AIDS knowledge and a higher degree of cognitive as well as negative symptoms. It could possibly be argued that individuals with more pronounced negative symptomatology might, despite their lack of knowledge, not be at an increased risk of contracting HIV/AIDS because their social and sexual contact may be impaired by their symptoms. However, our findings showed no significant difference in the presence of highrisk sexual behaviors between the participants with High and Low SANS scores. In fact, they reported a similar number of sexual partners and episodes of intercourse over a prescribed period; also, most of the patients (N⳱75), TABLE 3.
distributed over the full range of SANS scores, admitted to not using a condom during sexual intercourse. In this result, our findings differed from other studies. Cournos et al.30 investigated a group of 95 schizophrenia patients and found that increased incidence of positive symptoms could be associated with multiple partners, and increased overall psychopathology could be significantly correlated with sexual activity. In their sample of 178 patients with severe mental illness, McKinnon et al.26 demonstrated that the presence of more “excitement symptoms” coupled with fewer cognitive symptoms predicted increased sexual activity. Furthermore, increased positive symptoms were significantly associated with multiple partners, and excitement symptoms were associated with sex trade; however, no association could be demonstrated between any specific symptom and lack of condom use. In their empirical review, Kalichman et al.18 summarized the main contributors to risk-behaviors previously studied among severely mentally ill patients: 1) severity and symptomatology of their psychopathology; 2) alcohol and drug use before sexual behavior; 3) HIV-related knowledge deficits; 4) inaccurate perceptions of infection risk; and 5) environmental factors that influence lifestyle choices. Also, comorbid personality disorders and drugdependence disorders were identified as factors that could increase the risk of contracting HIV. Although a significant number of participants in our study admitted comorbid cannabis or alcohol abuse, no injection drug use (lifetime or current) was reported in our sample. This stands in contrast with the results of a comprehensive review of published studies about HIV riskbehaviors that reported a lifetime history of injection drug use in over 20% of patients with severe mental illness, with most users admitting to having shared needles.10 These behaviors placed them at high risk for HIV, STDs, and bloodtransmitted infections. However, our findings are in keep-
Principal-Components Analysis Component
Component Matrix Global Affective Changes Global Alogia Global Avolition/Apathy Global Anhedonia/Asociality Global Hallucinations Global Delusions Global Behavior Global Thought Processes
1
2
3
0.743 0.709 0.751 0.666 0.363 0.364 0.590 0.463
ⳮ0.351 ⳮ0.420 ⳮ0.181 ⳮ0.316 0.649 0.741 0.511 0.412
0.276 ⳮ0.051 ⳮ0.070 0.344 0.482 0.310 ⳮ0.352 ⳮ0.623
Extraction method: principal-components analysis: three components extracted.
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Psychosomatics 48:2, March-April 2007
Koen et al. ing with the general pattern of drug abuse in South Africa and, specifically, the Western Cape,31 and therefore intravenous drug use would probably be less of a contributing factor to the risk for contracting HIV in our study population. Carmen and Brady32 suggested cognitive deficits, affective instability, and behavioral impulsivity as possible factors contributing to increased HIV risk. Although it is not possible to draw direct comparisons between the above factors and items on the SANS and SAPS, we did not find any significant association between lack of HIV riskbehavior knowledge and inappropriate affect (SANS item) or any of the behavioral symptoms (SAPS). We did not formally assess cognitive functioning, but, in light of our findings, we would suggest that this be included in future studies as one of the variables of interest, because negative symptoms have been demonstrated to be related to cognitive deficit.33,34 The strengths of our study include our culturally and diagnostically homogeneous study population, as well as the use of a structured clinical interview for diagnostic purposes. Furthermore, although the members of the patient group were at different stages of illness, none of them were acutely behaviorally disturbed at the time of the interview; they also had to be able to provide accurate demographic information and concentrate for the duration of the full structured interview. Our sample also showed a demographic composition (mean age at interview, gender distribution, and employment status) comparable to that of other schizophrenia samples in developing countries.35,36 Although the gender distribution is similar to that of other reported schizophrenia samples,37 the relatively small number of female participants could make gender comparisons unreliable. The study was the first of its kind in a South African
schizophrenia population, and we demonstrated that although higher negative-symptom scores were shown to be significantly associated with poorer HIV/AIDS riskbehavior knowledge, increased knowledge levels were not associated with a decrease in risk-behavior participation. Given that the South African government, with the support of the international community, has funded numerous HIV/AIDS-prevention educational initiatives (e.g., extensive media campaigns and literature in all 11 national languages, as well as free condoms distributed at community centers and clinics; testing drives aimed specifically at pregnant women, and high-profile speakers touring all parts of the country), the relatively poor level of HIV/AIDS risk-behavior knowledge (especially significant in the group with high negative-symptom scores), as well as the lack of behavioral changes in the group with improved knowledge seems disappointing. Therefore, given that current HIV educational initiatives do not appear to meet the needs of our clients, we, as mental health professionals, have a clear obligation to advocate more specific programs tailored to empower our particularly vulnerable clientele in the fight against HIV/AIDS. Some evidence exists that intensive, small-group interventions that target a variety of risk-related dimensions could produce at least short-term reductions in high-risk sexual behavior among severely mentally ill patients.12,38 Such a community-based, small-group intervention strategy seems to be a viable option because it could more readily target a specific group and would also be in line with the South African government’s plan to prioritize community-based treatment for psychiatric patients by the year 2010. We have received financial support from the Harry and Doris Crossley Foundation and from a Lundbeck Community Research Grant.
References
1. Dorrington RE, Bradshaw D, Johnson L, et al: The Demographic Impact of HIV/AIDS in South Africa: National Indicators for 2004. Cape Town: Centre for Actuarial Research, South African Medical Research Council and Actuarial Society of South Africa, 2004 2. McKinnon K, Cournos F, Herman R: HIV among people with chronic mental illness. Psychiatr Quarterly 2002; 73:17–31 3. Otto-Salaj LL, Stevenson LY: Influence of psychiatric diagnosis and symptoms on HIV risk-behavior in adults with serious mental illness. AIDS Reader 2001; 11:197–204 4. Cournos F, McKinnon K: HIV seroprevalence among people with severe mental illness in the United States: a critical review. Clin Psychol Rev 1997; 17:259–269 5. Rosenberg SD, Swanson JW, Wolford GI, et al: The five-site health
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and risk study of blood-borne infections among persons with severe mental illness. Psychiatr Serv 2003; 54:827–835 6. UNAIDS: Basic Facts About the HIV/AIDS Epidemic and Its Impact. Geneva, Switzerland, World Health Organization, 2004 7. Brady SM, Carman EH: AIDS risk in the mentally ill: clinical strategies for prevention, in New Directions for Mental Health Services. Edited by Goldfinger SM. San Francisco, CA, JosseyBass, 1990 8. Gray R, Brewin E: A review of the literature on HIV infection and schizophrenia: implications for research, policy, and clinical practice. J Psychiatry Ment Health Nurs 2002; 9:405–409 9. Carey MP, Carey KB, Maisto SA, et al: Reducing HIV riskbehavior among adults receiving outpatient psychiatric treatment:
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HIV/AIDS Risk-Behavior in Schizophrenia results from a randomized, controlled trial. J Consult Clin Psychol 2004; 72:252–268 10. Meade CS, Sikkema KJ: HIV risk-behavior among adults with severe mental illness: a systematic review. Clin Psychol Rev 2005; 25:433–457 11. Carey MP, Carey KB, Weinhardt LS, et al: Documented behavioral risk for human immunodeficiency virus (HIV) infection among seriously mentally ill outpatients. Community Ment Health J 1997; 33:133–142 12. Kelly JA: HIV risk-reduction interventions for persons with severe mental illness. Clin Psychol Rev 1997; 17:293–309 13. Kelly JA, Murphy DA, Bahr GR, et al: AIDS/HIV risk-behavior among the chronic mentally ill. Am J Psychiatry 1992; 149:886– 889 14. Sacks MH, Perry S, Graver R, et al: Self-reported HIV-related risk behaviors in acute psychiatric inpatients: a pilot study. Hosp Community Psychiatry 1990; 41:1253–1255 15. Carey MP, Carey KB, Kalichman SC: Risk for human immunodeficiency virus (HIV) among persons with severe mental illness. Clin Psychol Rev 1997; 17:271–291 16. Grassi L, Biancosino B, Righi R, et al: Knowledge about HIV transmission and prevention among Italian patients with psychiatric disorders. Psychiatr Serv 2001; 52:679–681 17. Baillargeon J, Duncate S, Pulvino J, et al: The association of psychiatric disorders and HIV infection in the correctional setting. Ann Epidemiol 2003; 13:606–612 18. Kalichman SC, Carey MP, Carey KB: Human immunodeficiency virus (HIV) risk among the seriously mentally ill: review of empirical studies. Clinical Psychology: Science and Practice 1996; 3:130–143 19. Kalichman SC, Kelly JA, Johnson JR, et al: Factors associated with risk for HIV infection among chronic mentally ill adults. Am J Psychiatry 1994; 151:221–227 20. Emsley RA, Niehaus DJH, Mbanga NI, et al: The factor structure of positive and negative symptoms in South African Xhosa patients with schizophrenia. Schizophr Res 2001; 47:149–157 21. Andreasen NC: The Scale for the Assessment of Negative Symptoms (SANS): conceptual and theoretical foundations. Br J Psychiatry 1989; 155:49–52 22. Andreasen NC: Methods for assessing positive and negative symptoms. Modern Problems in Pharmacopsychiatry 1990; 24:73–88 23. American Psychiatric Association: The Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. Washington, DC, American Psychiatric Publishing, 1994 24. Nurnberger JI, Blehar MC, Kaufmann CA, et al: Diagnostic In-
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terview for Genetic Studies: rationale, unique features, and training. NIMH Genetics Initiative Arch Gen Psychiatry 1994; 51:849– 859 25. Kelly JA, St. Lawrence JS, Hood HV, et al: An objective test of AIDS risk-behavior knowledge: scale development, validation, and norms. J Behav Ther Exp Psychiatry 1989; 20:227–234 26. McKinnon K, Cournos F, Sugden R, et al: The relative contributions of psychiatric symptoms and AIDS knowledge to HIV riskbehaviors among people with severe mental illness. J Clin Psychiatry 1996; 57:506–513 27. Koen L, Van Vuuren S, Niehaus DJH, et al: HIV/AIDS riskbehaviour knowledge in a South African schizophrenia population. S Afr J Psychiatry 2004; 10:90 28. Lyon D: Human immunodeficiency virus (HIV) disease in persons with severe mental illnesses. Issues Ment Health Nurs 2001; 22:109–119 29. Kay SR, Fiszbein A, Opler LA: The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophr Bull 1987; 13:261–275 30. Cournos F, Guido J, Coomaraswamy S, et al: Sexual activity and risk of HIV infection among patients with schizophrenia. Am J Psychiatry 1994; 151:228–232 31. SACENDU (South African Community Epidemiology Network on Drug Use): Monitoring Alcohol and Drug Abuse Trends in South Africa. July–Dec 2004. Phase 17, 2005 32. Carmen E, Brady SM: AIDS risk and prevention for the chronic mentally ill. Hosp Community Psychiatry 1990; 41:682–687 33. Galderisi S, Maj M, Mucci A, et al: Historical, psychopathological, neurological, and neuropsychological aspects of deficit schizophrenia: a multicenter study. Am J Psychiatry 2002; 159:983–990 34. Poole JH, Ober BA, Shenaut GK, et al: Independent frontal-system deficits in schizophrenia: cognitive, clinical, and adaptive implications. Psychiatry Res 1999; 85:161–176 35. Kebede D, Alem A, Shibre T, et al: Short-term symptomatic and functional outcomes of schizophrenia in Butajira, Ethiopia. Schizophr Res 2005; 78:171–185 36. Kurihara T, Kato M, Reverger R, et al: Never-treated patients with schizophrenia in the developing country of Bali. Schizophr Res 2005; 79(2–3):307–313 37. McGrath JJ: Myths and plain truths about schizophrenia epidemiology: The Nape Lecture, 2004. Acta Psychiatr Scand 2005; 111:4–11 38. Berkman A, Cerwonka E, Sohler N, et al: A randomized trial of brief HIV risk-reduction intervention for men with severe mental illness. Psychiatr Serv 2006; 57:407–409
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Schizophrenia sufferers have been demonstrated to have relatively poor HIV/AIDS risk-behavior knowledge and, as a group, are found to be particularly vulnerable to contracting HIV. The authors asked whether an association could be demonstrated between specific symptoms and differing levels of knowledge. A structured clinical interview and HIV/AIDS Risk Questionnaires were administered to 102 subjects, and a principal-component analysis was performed for global and individual items, followed by comparisons between factors. Three factors (negative, positive, and global thought-disorder) emerged as significant between poor HIV/AIDS risk-behavior knowledge and higher negative-symptom scores. Findings support the notion that existing educational programs should be adapted to target specific areas of deficit. (Psychosomatics 2007; 48:128–134)
S
outh Africa is home to 46 million people, of which 5.3 million are estimated to be HIV-positive, representing a total population prevalence rate of 11%—one of the highest in the world.1 Studies have indicated that people living with a serious mental illness are particularly vulnerable to contracting HIV.2,3 Reported rates of infection in mentally ill patients range from 3.1% to 22% (no South African data exist), in comparison to reported ranges of between 0.6% and 11% in the general population.4–6 The popular misconception that severely mentally ill persons lack the skills to form intimate relationships or have less need to do so led to the underestimation of the risk of HIV infection in this population during the first decade of the AIDS epidemic.7 Even now, many contemporary mental-health policy reports fail to discuss the risk Received December 21, 2005; revised March 13, 2006; accepted March 20, 2006. From the Ngaphakathi Workgroup, Dept. of Psychiatry, Univ. of Stellenbosch, Cape Town, South Africa. Send correspondence and reprint requests to Dr. Liezl Koen, P.O. Box 19063, Tygerberg 7505 South Africa. e-mail: [email protected] Copyright 䉷 2007 The Academy of Psychosomatic Medicine
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of HIV/AIDS in people with severe mental illness, and there are few specific references to sexual-health promotion in these documents.8 In fact, studies examining high-risk sexual behaviors among adults with severe mental illness have indicated that not only do they often engage in such behaviors (e.g., unprotected intercourse, multiple partners, sex trade, and intravenous drug use),9,10 but they also underestimate the risk of infection.11,12 They report little fear of contracting HIV,13,14 with their perception of personal risk of infection ranging from none to low.15 Furthermore, comparative studies have revealed that people with severe mental illness (and specifically those with a diagnosis of schizophrenia)16 exhibit lower levels of HIV/AIDS risk-behavior knowledge than is found in the general population.9,17 It is well known that a wide spectrum of clinical presentations are exhibited in schizophrenia. Therefore, rather than just accept that it is mainly a lack of information or inaccurate information about HIV infection that contributes to the poor levels of HIV/AIDS risk-behavior knowlPsychosomatics 48:2, March-April 2007
Koen et al. edge in patients with schizophrenia,18 we may find that clinical factors such as poor reality-perception, affective instability, formal thought disorder, and impulsivity may be even more important causes of this relatively poor knowledge level. Although a number of studies worldwide have examined levels of HIV/AIDS risk-behavior knowledge in patients with schizophrenia,13,16,19 a paucity of data exist on whether specific symptoms or symptom clusters contribute to the differing levels of HIV knowledge (or lack thereof) within specific schizophrenia populations. Factor analysis is one of the methods that could be used to determine symptom structure by utilizing the data collected with measures that have been specifically developed to explore the relationships between the various symptoms of schizophrenia. In a practical application of this technique in psychiatric illness, Emsley et al.20 investigated the factor structure of both the global and individual items of the Schedule for the Assessment of Negative Symptoms (SANS)21 and the Schedule for the Assessment of Positive Symptoms (SAPS)22 in a large sample of South African Xhosa patients with schizophrenia. Their analysis (principalcomponent analysis [PCA] with varimax rotation; eigenvalues ⬎1) yielded a two-factor solution representing positive and negative symptoms, which accounted for 59.9% of the variance. Analysis of global ratings also revealed a five-factor model (less strict eigenvalue criteria, accounting for 85% of the variance) that was consistent with previous studies, where the first two factors were the same as those of the two-factor analysis (negative and positive dimensions), and the other three consisted of attentional impairment, alogia, and a disorganizational factor. By producing findings that were very similar to that of studies done in other parts of the world, the authors provided evidence supporting the notion that the factor structure for the symptoms of schizophrenia is relatively resistant to cultural influences. This five-factor model provides a theoretical framework in which specific symptom domains can be identified and then assessed for their influence on specific variables, such as the level of knowledge of HIV risk-behaviors in patients with schizophrenia. Indeed, if such an association could be demonstrated, healthcare workers could utilize clinical presentation to identify individuals likely to have poor knowledge. Our study therefore aimed to identify whether specific symptom domains could be shown to be associated with differing levels of HIV/AIDS risk-behavior knowledge in schizophrenia patients. Psychosomatics 48:2, March-April 2007
METHOD Subjects and Assessments Patients were recruited from the Stikland Psychiatric Hospital Catchment area (Cape Town, South Africa) as part of a larger, ongoing genetic study. The group consisted of 102 Xhosa patients with a diagnosis of schizophrenia,23 who were at various stages of illness at the time of the interview. The Xhosa are one of the indigenous populations of South Africa and form part of the Nguni-language group. Adult patients (age 18–65 years), both men and women, were included. Each participant was interviewed by a clinician, who administered a standardized interview (the Diagnostic Interview for Genetic Studies [DIGS] Version 2.0)24 in English, Afrikaans, and/or Xhosa (with the help of an interpreter). The DIGS includes the SANS and the SAPS. The interviewers used hospital and clinic chart records (where available) and information gathered from family members to complete these interviews. A urinary drug screen was also performed on all participants. The AIDS Risk-Behavior Assessment Questionnaire (ARBAQ; Table 1) and the AIDS Risk-Behavior Knowledge Questionnaire (ARBKQ;13 Table 2) were also administered by a clinician. Also, individuals were asked whether they believed that AIDS could be transmitted via their depot antipsychotic injection. The ARBAQ is a tool used by researchers to determine to what extent participants encounter or participate in potentially high-risk sexual behaviors. The scale used was adapted from a similar scale25,26 by the MRC Unit on Anxiety Disorders, affiliated with the Department of Psychiatry, University of Stellenbosch, South Africa. The ARBKQ is an 11-item True/False questionnaire that assesses an individual’s knowledge about the cause and potential transmission of HIV/AIDS. The items used are believed to be those most pertinent to assess knowledge in this population and were adapted by the original author from a previously normed and validated 40-item scale.25 The study was approved by the committee for Human Research of the University of Stellenbosch, and their ethical guidelines were strictly adhered to at all times. Statistical Analysis A principal-component analysis (PCA) with varimax rotation and eigenvalues ⬎1 was performed on the participating group for the nine global ratings and on the individual items of the SANS and SAPS. The global scores of each of the item groups (affective changes, alogia, http://psy.psychiatryonline.org
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HIV/AIDS Risk-Behavior in Schizophrenia avolition/apathy, anhedonia, hallucinations, delusions, thought-disorder, and behavioral changes) were summed in line with factor-structure findings (e.g., the negativesymptom factor score comprised global scores of affective changes, alogia, avolition/apathy, and anhedonia. Next, the total number of correct responses was calculated for the ARBKQ, and we compiled descriptive statistics, calculating the mean, median, and mode, and the sample was then dichotomized around the median (taking into consideration the mean and mode). On the basis of this method, we dichotomized the level of knowledge into High score (⬎7) and Low score (ⱕ7). Student t-tests were then used to compare the High- and Low-scoring groups in terms of the nine global items on the SANS and SAPS, to the individual items of the SANS and the symptom factors identified earlier. Subsequently, the negative-symptom domain was dichotomized around the median (score: 9), and chi-square or Student t-tests were used to determine whether any sigTABLE 1.
nificant association existed between the level of negative symptoms and number of sex partners, number of sexual encounters, and condom use. RESULTS Demographics Our sample comprised 102 Xhosa schizophrenia patients (76 men, 26 women), with a mean age of 32.28 (standard deviation [SD] 9.66) years. The majority of the patients were single (N⳱79); 10 were married, 6 were divorced, 5 were separated, and 2 were widowed. Nearly half (N⳱50) were unemployed; 45 were receiving a disability grant, and only 7 had regular employment. In all, 70 participants had a regular partner or spouse at the time of the interview, and 44 had had sex in the last 6 months. The majority of the patients (N⳱75) had not used a condom the last time they had had sex. Most
HIV/AIDS Risk-Behaviour Assessment Questionnaire Yes
1 2 3 4 4.1 4.2 4.3 5 6 7 8 9 9.1 9.2 9.3 9.4 10
Do you currently have a partner/spouse? Have you had sex in the last 6 months? Did you use a condom with your last sexual encounter? Have you had sex in exchange for: Money? Drugs? Place to stay? Have you had sex with a partner who used injected drugs? Have you had sex after using alcohol/drugs? Have you had sex with someone you have known for less than 24 hours? Have you been pressured into unwanted sex or been raped? Who was your first sexual partner? A regular partner or spouse Casual partner Rape Other/Unsure Age at time of first sexual encounter, years mean (standard deviation)
TABLE 2.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
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68.6% 43.1% 24.5% 7.8% 1% 5.9% 7.8% 28.4% 32.4% 7.8% 92.2% 4.9% 1% 1.9% 16.9 (2.8)
HIV/AIDS Risk-Behaviour Knowledge Questionnaire
Most people become sick quickly after getting the AIDS virus. Women can’t get AIDS if they only have sex with men. People who can give you the AIDS virus always look sick. Men can’t get AIDS if they only have sex with women. Washing after sex stops AIDS. Only gay (homosexual) men get AIDS. You must have many sex partners to get AIDS. Sex with someone who has used injected drugs creates risk for AIDS. Using condoms (rubbers) can help prevent AIDS. Unborn babies can get AIDS from their mothers. You can get the AIDS virus through one sexual contact.
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Correct Answer
Patients Correct
False False False False False False False True True True True
39.2% 73.5% 48% 66.7% 77.5% 56.9% 52.9% 58.8% 81.4% 80.4% 68.6%
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Koen et al. (N⳱94), reported that their first sexual partner had been their regular partner or spouse; five had their first experience with a casual partner, and one reported having been raped. High-Risk Behaviors With regard to high-risk sexual behaviors, eight patients admitted to having had sex in the past in exchange for money, one for drugs, and six for a place to stay. Only eight had had sex with a partner who used intravenous drugs. Twenty-nine admitted to having had sexual intercourse after using alcohol or drugs, and 33 had had sex with a partner they had known for less than 24 hours. Eight reported that at some stage they had been pressured into unwanted sex or been raped. (See Table 1 for a full summary of results.) Comorbid Substance Abuse Lifetime comorbid alcohol abuse could be documented in 30 participants and cannabis abuse in 47 cases. A total of 67 admitted to abusing either alcohol or cannabis or both on a regular basis. A urinary drug-screen revealed a positive cannabis result in 11 cases. No lifetime or current injection drug abuse was documented in any of the participants. A large majority (N⳱76) were regular tobacco smokers. AIDS Risk-Behavior Knowledge Questionnaire On the ARBKQ, out of a possible score of 11, the mean was 7.05 (SD: 1.77); the median, 7.0; and the mode, 8.0. (See Table 2 for a full summary of the results.) A number of interesting knowledge deficits were revealed. Nearly two-thirds (N⳱60) thought that most people become sick quickly after getting the AIDS virus, and more than half (N⳱53) believed that people who transmit the AIDS virus always look sick. Forty percent (N⳱41) thought that only homosexual men were at risk for contracting AIDS. Nearly one-third (N⳱32) believed that one could not get AIDS through just one sexual contact, and nearly half (N⳱48) believed that one would have to have had many sexual partners to contract AIDS. As to the question of whether AIDS could be transmitted via the depot antipsychotic injection, seven of the participants indicated that they believed this to be true. Principal-Components Analysis (PCA) The results of the PCA revealed three factors with an eigenvalue ⬎1. (See Table 3 for full results.) Together, Psychosomatics 48:2, March-April 2007
these three factors accounted for 66.58% of the variance. The first factor, accounting for 33.78% of the variance, represented the negative-symptom dimension (eigenvalue: 3.04). Global affect, alogia, avolition, and anhedonia loaded high on this factor, whereas behavior loaded only to a lesser extent. The second factor represented the positive-symptom dimension (eigenvalue: 1.83), with hallucinations and delusions loading high. The third factor (eigenvalue: 1.11) largely comprised global thought-disorder. Comparison When assessing the levels of knowledge of HIV riskbehaviors by each of these factors, a statistically significant difference was shown for the negative-symptom factor. A high negative-symptom factor score (SANS ⬎9) was shown to be significantly associated with poorer HIV riskbehavior knowledge (ⱕ7 correct answers; p⳱0.015). No association could be demonstrated between SAPS scores and any of the factors. There was no statistically significant difference between the number of sexual encounters or sexual partners (past 6 months) or other risk behaviors when the Low and High negative-symptom score groups were compared with each other. Looking at the individual items of the SANS, the most significant contributing items to the PCA factors were poor grooming (p⳱0.005), latency (p⳱0.011), thought content (p⳱0.013), lack of intimacy (p⳱0.012), poor eye contact (p⳱0.019), and affective nonresponsiveness (p⳱0.036). Inappropriate affect did not seem to be a statistically significant contributing factor. We must note that the lack-ofintimacy item had a significantly skewed distribution and thus would be difficult to interpret within this data-set. DISCUSSION In keeping with worldwide findings, the results of our study confirmed the presence of high-risk sexual behaviors within the context of the relatively poor HIV/AIDS riskbehavior knowledge in a South African population of schizophrenia patients. The participants could only achieve an average score of 65% (7.01 answers correct) on the AIDS Risk-Behavior Knowledge Questionnaire (ARBKQ) and, compared with a control population (average 81%; 8.99 correct), the schizophrenia group demonstrated significant overall and specific knowledge deficits with regard to HIV/AIDS risk-behavior knowledge.27 Our behavioral findings are not unique to this study http://psy.psychiatryonline.org
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HIV/AIDS Risk-Behavior in Schizophrenia group but merely reflect the universally consistently high rates of HIV/AIDS-related risk-behaviors among adults with severe mental illness, as highlighted by several review articles.2–4,10,28 However, the main aim of our study was to investigate whether differing levels of risk-behavior knowledge within the study group could possibly be associated with the presence of specific clinical symptoms or symptom clusters. Our results showed that a higher score on the negativesymptom domain significantly correlated with poorer knowledge about HIV/AIDS risk-behavior as measured by the ARBKQ (⬍7 correct responses). Furthermore, the individual items in the negative-symptom domain, that is, poor grooming, speech latency, poor thought content, poor eye contact, and affective nonresponsiveness, were also demonstrated to be significantly associated with poorer risk-behavior knowledge. A literature search revealed only one previous study that specifically attempted to look at correlations between psychiatric symptoms and levels of HIV/AIDS knowledge. McKinnon et al.26 interviewed 178 psychiatric patients (various diagnoses) and also completed a Positive and Negative Syndrome Scale29 for each. These scores were then used to demonstrate that a significant relationship existed between poorer HIV/AIDS knowledge and a higher degree of cognitive as well as negative symptoms. It could possibly be argued that individuals with more pronounced negative symptomatology might, despite their lack of knowledge, not be at an increased risk of contracting HIV/AIDS because their social and sexual contact may be impaired by their symptoms. However, our findings showed no significant difference in the presence of highrisk sexual behaviors between the participants with High and Low SANS scores. In fact, they reported a similar number of sexual partners and episodes of intercourse over a prescribed period; also, most of the patients (N⳱75), TABLE 3.
distributed over the full range of SANS scores, admitted to not using a condom during sexual intercourse. In this result, our findings differed from other studies. Cournos et al.30 investigated a group of 95 schizophrenia patients and found that increased incidence of positive symptoms could be associated with multiple partners, and increased overall psychopathology could be significantly correlated with sexual activity. In their sample of 178 patients with severe mental illness, McKinnon et al.26 demonstrated that the presence of more “excitement symptoms” coupled with fewer cognitive symptoms predicted increased sexual activity. Furthermore, increased positive symptoms were significantly associated with multiple partners, and excitement symptoms were associated with sex trade; however, no association could be demonstrated between any specific symptom and lack of condom use. In their empirical review, Kalichman et al.18 summarized the main contributors to risk-behaviors previously studied among severely mentally ill patients: 1) severity and symptomatology of their psychopathology; 2) alcohol and drug use before sexual behavior; 3) HIV-related knowledge deficits; 4) inaccurate perceptions of infection risk; and 5) environmental factors that influence lifestyle choices. Also, comorbid personality disorders and drugdependence disorders were identified as factors that could increase the risk of contracting HIV. Although a significant number of participants in our study admitted comorbid cannabis or alcohol abuse, no injection drug use (lifetime or current) was reported in our sample. This stands in contrast with the results of a comprehensive review of published studies about HIV riskbehaviors that reported a lifetime history of injection drug use in over 20% of patients with severe mental illness, with most users admitting to having shared needles.10 These behaviors placed them at high risk for HIV, STDs, and bloodtransmitted infections. However, our findings are in keep-
Principal-Components Analysis Component
Component Matrix Global Affective Changes Global Alogia Global Avolition/Apathy Global Anhedonia/Asociality Global Hallucinations Global Delusions Global Behavior Global Thought Processes
1
2
3
0.743 0.709 0.751 0.666 0.363 0.364 0.590 0.463
ⳮ0.351 ⳮ0.420 ⳮ0.181 ⳮ0.316 0.649 0.741 0.511 0.412
0.276 ⳮ0.051 ⳮ0.070 0.344 0.482 0.310 ⳮ0.352 ⳮ0.623
Extraction method: principal-components analysis: three components extracted.
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Koen et al. ing with the general pattern of drug abuse in South Africa and, specifically, the Western Cape,31 and therefore intravenous drug use would probably be less of a contributing factor to the risk for contracting HIV in our study population. Carmen and Brady32 suggested cognitive deficits, affective instability, and behavioral impulsivity as possible factors contributing to increased HIV risk. Although it is not possible to draw direct comparisons between the above factors and items on the SANS and SAPS, we did not find any significant association between lack of HIV riskbehavior knowledge and inappropriate affect (SANS item) or any of the behavioral symptoms (SAPS). We did not formally assess cognitive functioning, but, in light of our findings, we would suggest that this be included in future studies as one of the variables of interest, because negative symptoms have been demonstrated to be related to cognitive deficit.33,34 The strengths of our study include our culturally and diagnostically homogeneous study population, as well as the use of a structured clinical interview for diagnostic purposes. Furthermore, although the members of the patient group were at different stages of illness, none of them were acutely behaviorally disturbed at the time of the interview; they also had to be able to provide accurate demographic information and concentrate for the duration of the full structured interview. Our sample also showed a demographic composition (mean age at interview, gender distribution, and employment status) comparable to that of other schizophrenia samples in developing countries.35,36 Although the gender distribution is similar to that of other reported schizophrenia samples,37 the relatively small number of female participants could make gender comparisons unreliable. The study was the first of its kind in a South African
schizophrenia population, and we demonstrated that although higher negative-symptom scores were shown to be significantly associated with poorer HIV/AIDS riskbehavior knowledge, increased knowledge levels were not associated with a decrease in risk-behavior participation. Given that the South African government, with the support of the international community, has funded numerous HIV/AIDS-prevention educational initiatives (e.g., extensive media campaigns and literature in all 11 national languages, as well as free condoms distributed at community centers and clinics; testing drives aimed specifically at pregnant women, and high-profile speakers touring all parts of the country), the relatively poor level of HIV/AIDS risk-behavior knowledge (especially significant in the group with high negative-symptom scores), as well as the lack of behavioral changes in the group with improved knowledge seems disappointing. Therefore, given that current HIV educational initiatives do not appear to meet the needs of our clients, we, as mental health professionals, have a clear obligation to advocate more specific programs tailored to empower our particularly vulnerable clientele in the fight against HIV/AIDS. Some evidence exists that intensive, small-group interventions that target a variety of risk-related dimensions could produce at least short-term reductions in high-risk sexual behavior among severely mentally ill patients.12,38 Such a community-based, small-group intervention strategy seems to be a viable option because it could more readily target a specific group and would also be in line with the South African government’s plan to prioritize community-based treatment for psychiatric patients by the year 2010. We have received financial support from the Harry and Doris Crossley Foundation and from a Lundbeck Community Research Grant.
References
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