AIDS Care, 2014 Vol. 26, No. 8, 1032–1035, http://dx.doi.org/10.1080/09540121.2014.894618
Risk factors for suicide attempts in a clinic-based sample of people living with HIV in Puerto Rico Gerardo G. Jovet-Toledoa*, Michael C. Clattsa, Carlos E. Rodriguez-Diaza, Lloyd Goldsamtb and Ricardo L. Vargas-Molinaa a
Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico; bNational Development and Research Institutes, New York, NY, USA (Received 15 October 2013; accepted 11 February 2014) Puerto Rico (PR) has a large and rapidly growing population of people living with HIV. However, relatively little behavioral or clinical research has been done in this population. As treatment for HIV increasingly moves into a chronic condition model, it is becoming increasingly important to understand the needs of this population so critical social and behavioral interventions can be developed, thus enabling the individual and community-level benefits of antiretroviral (ARV) treatment to be fully realized. To date, however, there has been very little research on the mental health needs of people living with HIV in PR, a fact that constrains intervention development and implementation. This paper describes data from a public sexually transmitted infection (STI) and HIV clinic study in the San Juan metropolitan area between April 2010 and December 2012 (n = 1185), roughly a third (36%) of whom are living with HIV. Descriptive statistics, chi-square, t-tests, and binary logistic regressions were used to assess associations between HIV status and a history of suicide attempt. The overall prevalence of a history of suicide attempt was 20.4%. No statistically significant relationship was found between a history of suicide attempt and being HIV positive, although people with HIV infection did evidence a higher prevalence of attempts than HIV-negative subjects (23.4% vs. 19.0%). Factors associated with having a history of suicide attempt within the overall sample included gender, current employment status, a lifetime history of drug use, and a lifetime history of sex work. Similar patterns were seen in the HIV-positive subsample. There was a nonsignificant trend toward increased risk for a post-diagnosis suicide attempt. These findings suggest that additional research on mental health risks among populations at risk for HIV in PR is needed. Keywords: suicide; HIV; mental health; Puerto Rico; people living with HIV
Introduction Despite the success of antiretroviral (ARV) treatment in transforming HIV into a chronic, treatable condition, rates of suicide ideation and suicide attempts among people living with HIV are generally higher than among HIV negative or status unknown individuals (Keiser et al., 2010; Sherr et al., 2008). Several researchers have suggested that HIV-related stigma may contribute to social isolation and decreased quality of life, thereby contributing to higher rates of suicide among people living with HIV (MacQuarrie, Eckhaus, & Nyblade, 2009; Nachega et al., 2012). Puerto Rico (PR) has the highest suicide rate among Hispanics in the USA (6.9 per 100,000) (Centers for Disease Control and Prevention [CDC], 2010). PR also has one of the highest incidence rates of HIV in the USA; almost twice that of the 50 states and 1.5 times the HIV incidence among non-PR Hispanics in the USA (CDC, 2009). Surprising given the confluence of these two trends in PR (high background HIV seroprevalence and incidence and high rates of suicide), there is relatively little detailed data on suicide in PR and hence little empirical *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
foundation for guiding development of social policy and prevention programming for the island’s large and growing population of people living with HIV. Based on analysis of a limited amount of suicide-related data that derived from an ongoing epidemiological study in a publicly funded sexually transmitted infection (STI) and HIV treatment center in the San Juan metropolitan area, this paper provides a preliminary report of the prevalence of suicide among people living with HIV in PR and identifies key areas for future research and intervention development.
Methods Details of the study design and methodology have been described elsewhere (Clatts et al., 2011). Briefly, study subjects were randomly selected from the patient waiting room at Centro Latinoamericano de Enfermedades de Transmisión Sexual, one of the largest STI/HIV screening and treatment centers in the San Juan metropolitan area and invited to participate in a structured, survey interview. Eligibility was restricted to individuals who
AIDS Care were at least 16 years of age. About 77% of eligible subjects agreed to participate. The survey, administered by an interviewer, included questions on socio-demographic characteristics, history of drug use, history of risky sexual practices, as well as health history and use of health services (including selfreported history of diagnosis with STIs and HIV). A total of 1185 subjects participated in the study between April 2010 and December 2012. Descriptive statistics, t-tests, and chi-square tests were used to assess differences between those who had attempted suicide at least once during their lifetime and those who had not. Additionally, binary logistic regression was used to further explore the relationship between having a history of suicide attempt and self-reported HIV status, and to identify possible risk factors for suicide attempts. Results More than half the samples (58.9%) are men. Mean age is 36.9 years; 87.6% reside in the San Juan metropolitan area. Consistent with the fact the clinic generally attracts a high-risk population, 44.0% have a history of drug use (including heroin, cocaine, and/or crack) and 23.8% have a history of drug injection; 16.9% of the males have a history of having sex with men (MSM); 8.5% of the sample (both males and females) have a history of sex work. One out of five subjects (20.6%) in the overall sample has attempted suicide at least once in their lifetime. A third (36%) of the overall sample is living with HIV. Two parallel regression analyses of risk factors for suicide were conducted, one for the overall sample and one for the HIV-positive subgroup. Independent variables were derived from those that were shown to have been significant (p-value < 0.05) in bivariate analyses. Additional variables were included based on the evidence found in the literature. Statistically significant differences found between those with a history of suicide attempts and those with no history of suicide attempts, included gender, place of birth, annual income, being a student, being unemployed, history of drug use, early age at first sexual experience, and history of sex work. Although no statistically significant difference was observed in bivariate analysis, higher rates of prior suicide attempts were observed among the HIV-positive subgroup. As included in Table 1, when controlling for other factors in the regression analysis, no statistically significant relationship between a history of prior suicide attempts and HIV status was sustained. Nonetheless, gender (being female) (p = 0.017), employment status (being unemployed) (p = 0.004), history of drug use (p < 0.001), and history of sex work (p < 0.001) were associated with having a history of suicide attempt.
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Table 1. Binary logistic regression analysis of the sociodemographic characteristics associated with having a lifetime history of suicide attempt for the general sample and the HIVpositive men and women.
General sample HIV positive Gender Male Female Employment Employed Exclusively unemployed Lifetime drug use Sex work Student Place of birth Puerto Rico USA Other Income None < $20,000 ≥ $20,000 Age first sexual practice HIV positive Age group 16–39 40 + Gender Male Female Employment Employed Exclusively unemployed Lifetime drug use Sex work
Odds ratio (95% CI)
p-Value
1.260 (0.876–1.812)
0.214
Ref. 1.614 (1.089–2.391)
0.017
Ref. (1.234–2.951) (1.754–3.914) (1.505–4.213) (0.251–1.516)
0.004
Risk factors for suicide attempts in a clinic-based sample of people living with HIV in Puerto Rico Gerardo G. Jovet-Toledoa*, Michael C. Clattsa, Carlos E. Rodriguez-Diaza, Lloyd Goldsamtb and Ricardo L. Vargas-Molinaa a
Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico; bNational Development and Research Institutes, New York, NY, USA (Received 15 October 2013; accepted 11 February 2014) Puerto Rico (PR) has a large and rapidly growing population of people living with HIV. However, relatively little behavioral or clinical research has been done in this population. As treatment for HIV increasingly moves into a chronic condition model, it is becoming increasingly important to understand the needs of this population so critical social and behavioral interventions can be developed, thus enabling the individual and community-level benefits of antiretroviral (ARV) treatment to be fully realized. To date, however, there has been very little research on the mental health needs of people living with HIV in PR, a fact that constrains intervention development and implementation. This paper describes data from a public sexually transmitted infection (STI) and HIV clinic study in the San Juan metropolitan area between April 2010 and December 2012 (n = 1185), roughly a third (36%) of whom are living with HIV. Descriptive statistics, chi-square, t-tests, and binary logistic regressions were used to assess associations between HIV status and a history of suicide attempt. The overall prevalence of a history of suicide attempt was 20.4%. No statistically significant relationship was found between a history of suicide attempt and being HIV positive, although people with HIV infection did evidence a higher prevalence of attempts than HIV-negative subjects (23.4% vs. 19.0%). Factors associated with having a history of suicide attempt within the overall sample included gender, current employment status, a lifetime history of drug use, and a lifetime history of sex work. Similar patterns were seen in the HIV-positive subsample. There was a nonsignificant trend toward increased risk for a post-diagnosis suicide attempt. These findings suggest that additional research on mental health risks among populations at risk for HIV in PR is needed. Keywords: suicide; HIV; mental health; Puerto Rico; people living with HIV
Introduction Despite the success of antiretroviral (ARV) treatment in transforming HIV into a chronic, treatable condition, rates of suicide ideation and suicide attempts among people living with HIV are generally higher than among HIV negative or status unknown individuals (Keiser et al., 2010; Sherr et al., 2008). Several researchers have suggested that HIV-related stigma may contribute to social isolation and decreased quality of life, thereby contributing to higher rates of suicide among people living with HIV (MacQuarrie, Eckhaus, & Nyblade, 2009; Nachega et al., 2012). Puerto Rico (PR) has the highest suicide rate among Hispanics in the USA (6.9 per 100,000) (Centers for Disease Control and Prevention [CDC], 2010). PR also has one of the highest incidence rates of HIV in the USA; almost twice that of the 50 states and 1.5 times the HIV incidence among non-PR Hispanics in the USA (CDC, 2009). Surprising given the confluence of these two trends in PR (high background HIV seroprevalence and incidence and high rates of suicide), there is relatively little detailed data on suicide in PR and hence little empirical *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
foundation for guiding development of social policy and prevention programming for the island’s large and growing population of people living with HIV. Based on analysis of a limited amount of suicide-related data that derived from an ongoing epidemiological study in a publicly funded sexually transmitted infection (STI) and HIV treatment center in the San Juan metropolitan area, this paper provides a preliminary report of the prevalence of suicide among people living with HIV in PR and identifies key areas for future research and intervention development.
Methods Details of the study design and methodology have been described elsewhere (Clatts et al., 2011). Briefly, study subjects were randomly selected from the patient waiting room at Centro Latinoamericano de Enfermedades de Transmisión Sexual, one of the largest STI/HIV screening and treatment centers in the San Juan metropolitan area and invited to participate in a structured, survey interview. Eligibility was restricted to individuals who
AIDS Care were at least 16 years of age. About 77% of eligible subjects agreed to participate. The survey, administered by an interviewer, included questions on socio-demographic characteristics, history of drug use, history of risky sexual practices, as well as health history and use of health services (including selfreported history of diagnosis with STIs and HIV). A total of 1185 subjects participated in the study between April 2010 and December 2012. Descriptive statistics, t-tests, and chi-square tests were used to assess differences between those who had attempted suicide at least once during their lifetime and those who had not. Additionally, binary logistic regression was used to further explore the relationship between having a history of suicide attempt and self-reported HIV status, and to identify possible risk factors for suicide attempts. Results More than half the samples (58.9%) are men. Mean age is 36.9 years; 87.6% reside in the San Juan metropolitan area. Consistent with the fact the clinic generally attracts a high-risk population, 44.0% have a history of drug use (including heroin, cocaine, and/or crack) and 23.8% have a history of drug injection; 16.9% of the males have a history of having sex with men (MSM); 8.5% of the sample (both males and females) have a history of sex work. One out of five subjects (20.6%) in the overall sample has attempted suicide at least once in their lifetime. A third (36%) of the overall sample is living with HIV. Two parallel regression analyses of risk factors for suicide were conducted, one for the overall sample and one for the HIV-positive subgroup. Independent variables were derived from those that were shown to have been significant (p-value < 0.05) in bivariate analyses. Additional variables were included based on the evidence found in the literature. Statistically significant differences found between those with a history of suicide attempts and those with no history of suicide attempts, included gender, place of birth, annual income, being a student, being unemployed, history of drug use, early age at first sexual experience, and history of sex work. Although no statistically significant difference was observed in bivariate analysis, higher rates of prior suicide attempts were observed among the HIV-positive subgroup. As included in Table 1, when controlling for other factors in the regression analysis, no statistically significant relationship between a history of prior suicide attempts and HIV status was sustained. Nonetheless, gender (being female) (p = 0.017), employment status (being unemployed) (p = 0.004), history of drug use (p < 0.001), and history of sex work (p < 0.001) were associated with having a history of suicide attempt.
1033
Table 1. Binary logistic regression analysis of the sociodemographic characteristics associated with having a lifetime history of suicide attempt for the general sample and the HIVpositive men and women.
General sample HIV positive Gender Male Female Employment Employed Exclusively unemployed Lifetime drug use Sex work Student Place of birth Puerto Rico USA Other Income None < $20,000 ≥ $20,000 Age first sexual practice HIV positive Age group 16–39 40 + Gender Male Female Employment Employed Exclusively unemployed Lifetime drug use Sex work
Odds ratio (95% CI)
p-Value
1.260 (0.876–1.812)
0.214
Ref. 1.614 (1.089–2.391)
0.017
Ref. (1.234–2.951) (1.754–3.914) (1.505–4.213) (0.251–1.516)
0.004
