Prevalence and associated factors of depressive and anxiety symptoms among HIV-infected men who have sex with men in China

Abstract

HIV-positive men who have sex with men (HIVMSM) face severe stigma and high levels of stressors, and have high prevalence of mental health problems (e.g., depression and anxiety). Very few studies explored the role of positive psychological factors on mental health problems among HIVMSM. The present study investigated the prevalence of two mental health problems (anxiety and depression), and their associated protective (gratitude) and risk (enacted HIV-related stigma, and perceived stress) factors among HIVMSM in China. A cross-sectional survey was conducted among 321 HIVMSM in Chengdu, China, by using a structured questionnaire. Over half (55.8%) of the participants showed probable mild to severe depression (as assessed by the Center of Epidemiologic Studies Depression scale); 53.3% showed probable anxiety (as assessed by the General Anxiety Disorder scale). Adjusted logistic regression models revealed that gratitude (adjusted odds ratio (ORa = 0.90, 95% confidence intervals (95% CI) = 0.86-0.94) was found to be protective, whilst perceived stress (ORa = 1.17, 95% CI = 1.12-1.22) and enacted stigma (ORa = 7.72, 95% CI = 2.27-26.25) were risk factors of depression. Gratitude (ORa = 0.95, 95% CI = 0.91-0.99) was also found to be protective whilst perceived stress (ORa = 1.19, 95% CI = 1.14-1.24) was a risk factor of anxiety. Gratitude did not moderate the associations found between related factors and poor mental health. It is warranted to promote mental health among HIVMSM, as depression/anxiety was highly prevalent. Such interventions should consider enhancement of gratitude, reduction of stress, and removal of enacted stigma as potential strategies, as such factors were significantly associated with depression/anxiety among HIVMSM.

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Prevalence and associated factors of depressive
and anxiety symptoms among HIV-infected men
who have sex with men in China
Jinghua Li, Phoenix K. H. Mo, Christopher W. Kahler, Joseph T. F. Lau,
Mengran Du, Yingxue Dai & Hanyang Shen
To cite this article: Jinghua Li, Phoenix K. H. Mo, Christopher W. Kahler, Joseph T. F. Lau,
Mengran Du, Yingxue Dai & Hanyang Shen (2016) Prevalence and associated factors of
depressive and anxiety symptoms among HIV-infected men who have sex with men in China, AIDS
Care, 28:4, 465-470, DOI: 10.1080/09540121.2015.1118430
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Prevalence and associated factors of depressive and anxiety symptoms among
HIV-infected men who have sex with men in China
Jinghua Li
a
, Phoenix K. H. Mo
a,b
, Christopher W. Kahler
c
, Joseph T. F. Lau
a,b,d
, Mengran Du
e
, Yingxue Dai
f
and
Hanyang Shen
g
a
Division of Behavioral Health and Health Promotion, The School of Public Health and Primary Care, Faculty of Medicine, The Chinese University
of Hong Kong, Shatin, Hong Kong;
b
The Chinese University of Hong Kong Shenzhen Research Institute, Shenzhen, People’s republic of China;
c
Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA;
d
Centre for Medical Anthropology
and Behavioral Health, Sun Yat-sen University, Guangzhou, People’s republic of China;
e
West China School of Public Health, Sichuan University,
People’s republic of China;
f
Chengdu Center for Disease Control and Prevention, Sichuan, People’s republic of China;
g
School of Public Health,
Drexel University, Philadelphia, USA
ABSTRACT
HIV-positive men who have sex with men (HIVMSM) face severe stigma and high levels of stressors,
and have high prevalence of mental health problems (e.g., depression and anxiety). Very few studies
explored the role of positive psychological factors on mental health problems among HIVMSM. The
present study investigated the prevalence of two mental health problems (anxiety and depression),
and their associated protective (gratitude) and risk (enacted HIV-related stigma, and perceived
stress) factors among HIVMSM in China. A cross-sectional survey was conducted among 321
HIVMSM in Chengdu, China, by using a structured questionnaire. Over half (55.8%) of the
participants showed probable mild to severe depression (as assessed by the Center of
Epidemiologic Studies Depression scale); 53.3% showed probable anxiety (as assessed by the
General Anxiety Disorder scale). Adjusted logistic regression models revealed that gratitude
(adjusted odds ratio (ORa = 0.90, 95% confidence intervals (95% CI) = 0.86–0.94) was found to be
protective, whilst perceived stress (ORa = 1.17, 95% CI = 1.12–1.22) and enacted stigma (ORa =
7.72, 95% CI = 2.27–26.25) were risk factors of depression. Gratitude (ORa = 0.95, 95% CI = 0.91–
0.99) was also found to be protective whilst perceived stress (ORa = 1.19, 95% CI = 1.14–1.24) was
a risk factor of anxiety. Gratitude did not moderate the associations found between related
factors and poor mental health. It is warranted to promote mental health among HIVMSM, as
depression/anxiety was highly prevalent. Such interventions should consider enhancement of
gratitude, reduction of stress, and removal of enacted stigma as potential strategies, as such
factors were significantly associated with depression/anxiety among HIVMSM.
ARTICLE HISTORY
Received 17 March 2015
Accepted 3 November 2015
KEYWORDS
Depression; gratitude;
stigma; perceived stress; men
who have sex with men
Introduction
Depression is prevalent among people living with HIV
(PLWH) in China (42.9–62.0%) (Wang et al., 2014;
Wu et al., 2015) and in countries such as the USA
(40.0%) (Simoni et al., 2012). It impacts drug adherence,
self-care (Langebeek et al., 2014), survival (Perry & Fish-
man, 1993), suicides (Carrico et al., 2007), and risk beha-
viors (Parsons, Halkitis, Wolitski, & Gomez, 2003)
negatively among PLWH.
HIV is prevalent among men who have sex with men
(MSM) (Oldenburg, Perez-Brumer, Reisner, & Mimiaga,
2015), which made up 21.4% of the PLWH in China
(2013) (National Health and Family Planning Commis-
sion of The People’s Republic of China, 2014). MSM
show disproportionately high prevalence of psychologi-
cal problems (World Health Organization, 2011). As
HIV-positive MSM (HIVMSM) experience dual sources
of stigma (Wu, 2012), their prevalence of psychological
problems is higher than that of MSM and PLWH in gen-
eral. Previous studies reported high prevalence of
depression (41.5%–58.6%) among HIVMSM (Brown,
Serovich, & Kimberly, 2015; Wilson, Stadler, Boone, &
Bolger, 2014), two of which were conducted in mainland
China (42.9% and 48.4%) (Wu, 2012; Wu et al., 2015).
Studies investigating risk factors of psychological pro-
blems are required to design effective prevention pro-
motion among HIVMSM. Stigma is defined as a
devalued identity that discredits a person in society
(Crocker, Major, & Steele, 1998). It includes perceived
stigma and enacted stigma (overt acts of discrimination
and humiliation) (Chi, Li, Zhao, & Zhao, 2014). Both
were associated with depression and anxiety among
PLWH in China (Liu, Gong, Yang, & Yan, 2014), but
such associations are unclear among HIVMSM. Per-
ceived stress occurs when “the environment that is
© 2015 Taylor & Francis
CONTACT Joseph T. F. Lau jlau@cuhk.edu.hk
AIDS CARE, 2016
VOL. 28, NO. 4, 465–470
http://dx.doi.org/10.1080/09540121.2015.1118430

being appraised by the person as taxing or exceeding his
or her resources and hence endangering his or her well-
being”(Lazarus & Folkman, 1984). It is a risk factor of
depression among PLWH in China (Su et al., 2013);
such an association has not been investigated among
HIVMSM.
Health workers should cultivate protective factors.
Unlike traditional psychology that focuses on abnormal-
ity, positive psychology attempts to enhance strengths in
life, such as optimism, gratitude, and positive affect
(Seligman & Csikszentmihalyi, 2000). Such factors
were negatively associated with mental health problems
among PLWH (Ironson et al., 2005; Moskowitz, 2003).
Gratitude, defined as a felt sense of wonder, thankful-
ness, and appreciation for life (Emmons & Shelton,
2002), is a part of positive psychology. It was negatively
associated with depression (Ng & Wong, 2013); it mod-
erated associations between some risk factors (e.g.,
stress) and depression (Krause, 2009). Interventions
can effectively enhance gratitude in some disease groups
(e.g., neuromuscular disease) (Emmons & McCullough,
2003).
We investigated the prevalence of depression and
anxiety, and the significance of two risk factors (enacted
HIV-related stigma and perceived stress) and one pro-
tective factor (gratitude) of depression/anxiety among
HIVMSM in Chengdu, China. We tested the hypotheses
that gratitude would moderate the associations between
the two risk factors and depression/anxiety.
Methods
Inclusion criteria were (1) men who had anal sex with
men in the last six months, (2) living in Chengdu,
China, (3) ≥18 years old, and (4) having been diagnosed
as HIV positive for ≥3 months. Participants were
assured that refusal would not affect their right to use
services and that they could quit any time. They were
given an incentive of RMB50 (about USD6). Ethics
approval was obtained from the Survey and Behavioural
Research Ethics Committee of the Chinese University of
Hong Kong. Our collaborating non-governmental organ-
ization (NGO) possessed 600 phone/email contacts out of
the 1000 HIVMSM identified in Chengdu (Feng et al.,
2010). We successfully contacted 350 (58.3%) and anon-
ymously interviewed 321 (91.7%) of them at the NGO
office with ensured privacy.
Background information was collected. The validated
Chinese version of the 20-item Center for Epidemiologic
Studies Depression (CES-D) scale (Song et al., 2008)
required participants to rate how often they have experi-
enced symptoms in the past seven days on a 4-point
Likert scale (range = 0–60; cut-off points were 16/21/25
for mild, moderate, and severe depressive symptoms;
Cronbach’s alpha = 0.92). The 7-item General Anxiety
Disorder (GAD) scale (Spitzer, Kroenke, Williams, &
Lowe, 2006) (4-point Likert scale; Cronbach’s alpha =
0.93; cut-off point >5 for probable anxiety disorder)
and the 6-item Gratitude Questionnaire (GQ-6)
(Emmons, McCullough, & Tsang, 2003) (7-point Likert
scale; Cronbach’s alpha = 0.80) were used. Furthermore,
one item for each of the eight subscales of the validated
Perceived Stress Scale for People living with HIV/AIDS
(PSSHIV) was selected to construct an 8-item scale on
perceived stress (Su et al., 2008) (Cronbach’s alpha =
0.85). Participants rated degree of enacted stigma experi-
enced (frequency of being discriminated, stigmatized, or
treated unfriendly due to their HIV serostatus) on a 4-
point Likert scale. Most of these scales (i.e., CES-D,
GAD, and GQ-6) have been used in Chinese
populations.
Multiple logistic regression models were fit for the two
dependent variables (depression and anxiety), adjusted
for background variables that were significant in the uni-
variate analysis. The moderation hypothesis was tested
by two interaction terms between the risk factors (per-
ceived stress and enacted stigma) and gratitude, using
-2 log likelihood (-2LL) statistics for nested models.
ORs and 95% CI were presented. SPSS 16.0 (SPSS Inc.,
Chicago, IL) was used. Significance referred to p< .05.
Results
Background characteristics are summarized (Table 1).
Prevalence of probable mild/moderate/severe depression
and anxiety was 14.6%/9.4%/31.8% and 32.1%/17.8%/
3.4%, respectively (mild to severe: 55.8%/53.3% for
depression/anxiety; Table 1).
Adjusted for self-perceived health, which was the only
significant background factor of probable (mild to
severe) depression (OR
u
= 0.10, 95% CI = 0.02, 0.44;
Table 2), perceived stress (OR
a
= 1.17, 95% CI = 1.12,
1.22) and enacted stigma (OR
a
= 7.72, 95% CI = 2.27,
26.25) were positively associated with, while gratitude
(OR
a
= 0.90, 95% CI = 0.86, 0.94) was negatively associ-
ated with probable depression (Table 3). Perceived stress
(OR
m
= 1.17, 95% CI = 1.12, 1.22), enacted stigma (OR
m
= 6.29, 95% CI = 1.69, 23.37), and gratitude (OR
m
= 0.90,
95% CI = 0.85, 0.94) remained significant when they
were included in the same model.
Adjusted for the two significant background variables
(self-perceived health and previous experience in taking
up CD4 testing), perceived stress (OR
a
= 1.19, 95% CI =
1.14, 1.24), but not enacted stigma (OR
a
= 2.07, 95% CI
= 0.90, 4.75), was positively associated with, while grati-
tude (OR
a
= 0.95, 95% CI = 0.91, 0.99) was negatively
466 J. LI ET AL

associated with probable anxiety (Table 3). Only per-
ceived stress (OR
m
= 1.18, 95% CI = 1.13, 1.24) remained
significant in the model that included all three variables.
Gratitude’s moderation for the associations between
the two risk factors (perceived stress and enacted stigma)
and depression/anxiety was non-significant (p< .05).
Discussion
We found prevalence of depression of 55%, which was
slightly higher than that of the two similar studies
(Wu, 2012; Wu et al., 2015). As only<9% of the
depressed PLWH in China had ever received treatment
(Jin et al., 2006), it is warranted to provide mental high
supportive/preventive services to HIVMSM in China.
Such services should both reduce risk factors (e.g., per-
ceived HIV-related stress and enacted stigma) and
enhance protective factors (e.g., gratitude).
The negative association between gratitude and
depression/anxiety is a novel finding. In the literature,
evidence-based positive psychological interventions,
including those cultivating trait gratitude (Seligman,
Steen, Park, & Peterson, 2005), are available. Note-
worthy, low-cost, simple, and effective gratitude inter-
ventions, such as “The Three Good Things”and the
“Gratitude Visit”exercise (Seligman et al., 2005), do
not require professional input, and can easily be incor-
porated into existing services, even in resource-limited
settings.
Like other studies targeting PLWH (Chi et al., 2014),
enacted stigma was significantly associated with
depression/anxiety among HIVMSM. As enacted stigma
may dissuade PLWH from seeking health-care services
Table 1. Background characteristics of HIVMSM.
Frequency
(N= 321)
Percentage
(%)
Demographic characteristics
Ethnicity
Han 315 98.1
Others 6 1.9
Residence (Hukou)
Chengdu 174 54.2
Others 147 45.8
Age
< = 25 88 27.4
26–30 100 31.2
31–40 96 29.9
>40 37 11.5
Education level
Primary school or below 3 0.9
Junior high school 31 9.7
Senior high school 95 29.6
University or above 192 59.8
Marital status
Single 203 63.2
Married/cohabiting with girlfriend 33 10.3
Cohabiting with boyfriend 63 19.6
Divorced/widow/others 22 6.9
Job
Full-time 215 67.0
Part-time 20 6.2
Unemployed 26 8.1
Retired 3 0.9
Student 17 5.3
Individually owned business 29 9.0
Others 11 3.4
Personal monthly income
< = 1000 34 10.6
1001–3000 142 44.2
3001–5000 97 30.2
5001–7000 26 8.1
7001–10000 19 5.9
>10000 3 0.9
Sexual orientation
Homosexual 273 85.0
Heterosexual 2 0.6
Bisexual 39 12.1
Not sure 7 2.2
HIV-related characteristics
Years since diagnosed with HIV
<6 months 64 19.9
6 months–1 year 47 14.6
1–2 years 84 26.2
2–5 years 107 33.3
>5 years 19 5.9
HIV stage
Asymptomatic HIV infection 283 88.2
AIDS 38 11.8
CD4 count
<200 15 4.7
200–350 112 34.9
351–500 99 30.8
>500 65 20.2
Never conducted CD4 test 30 9.3
Disclosure to regular partners
(RP) since diagnosis
Have disclosed to all 129 40.2
Have disclosed to some 67 20.9
Have not disclosed to any RP 125 38.9
Disclosure to non-regular partners (NRP)
since diagnosis
Have disclosed to all 65 20.2
Have disclosed to some 54 16.8
Have not disclosed to NRP 202 62.9
Disclosure to female sexual partners since
diagnosis
(Continued)
Table 1. Continued.
Frequency
(N= 321)
Percentage
(%)
Have no female sexual partners 239 74.5
Have disclosed to all 19 5.9
Have disclosed to some 14 4.4
Have not disclosed to female sexual
partners
49 15.3
Self-perceived health
Very poor/poor 24 7.5
Fair 159 49.5
Good/very good 138 42.9
Mental health status
Probable cases of depression (CES-D)
No 142 44.2
Mild 47 14.6
Moderate 30 9.4
Severe 102 31.8
Probable cases of anxiety (GAD)
Little or no 150 46.7
Mild 103 32.1
Moderate 57 17.8
Severe 11 3.4
AIDS CARE 467

Table 2. Association between background variables and mental health among HIVMSM.
Depression Anxiety
Row% OR
u
(95%CI) pvalue Row% OR
u
(95%CI) pvalue
Demographic characteristics
Ethnic
Han 55.9 1.00 53.7 1.00
Others 50.0 0.79 (0.16, 3.97) 0.775 33.3 0.43 (0.08, 2.39) 0.336
Residence (Hukou)
Chengdu 59.2 1.00 54.0 1.00
Others 51.7 0.74 (0.47, 1.15) 0.178 52.4 0.94 (0.60, 1.45) 0.769
Age
< = 30 54.8 1.00 54.3 1.00
>30 57.1 1.10 (0.70, 1.72) 0.676 51.9 0.91 (0.58, 1.42) 0.674
Education level
Below university 58.1 1.00 54.3 1.00
University or above 54.2 0.85 (0.54, 1.34) 0.482 52.6 0.94 (0.60, 1.46) 0.770
Marital status
Single 58.1 1.00 56.7 1.00
Married/cohabiting with girlfriend 51.5 0.77 (0.37, 1.60) 0.477 51.5 0.81 (0.39, 1.70) 0.582
Cohabiting with boyfriend 52.4 0.79 (0.45, 1.40) 0.422 44.4 0.61 (0.35, 1.08) 0.091
Divorced/widow/others 50.0 0.72 (0.30, 1.74) 0.466 50.0 0.77 (0.32, 1.85) 0.551
Job
Full-time 55.8 1.00 53.0 1.00
Part-time/unemployed 55.7 0.99 (0.62, 1.59) 0.979 53.8 1.03 (0.65, 1.64) 0.899
Income
< = 3000 54.0 1.00 55.7 1.00
>3000 57.9 1.17 (0.75, 1.83) 0.478 50.3 0.81 (0.52, 1.25) 0.340
Sexual orientation
Homosexual 54.2 1.00 51.6 1.00
Heterosexual/bisexual/not sure 64.6 1.54 (0.81, 2.91) 0.184 62.5 1.56 (0.83, 2.93) 0.167
HIV-related characteristics
HIV diagnosed years
<6 months 62.5 1.00 56.3 1.00
> = 6 months 54.1 0.71 (0.40, 1.24) 0.226 52.5 0.86 (0.50, 1.49) 0.594
HIV stage
Asymptomatic HIV infection 54.8 1.00 52.7 1.00
AIDS 63.2 1.42 (0.70, 2.85) 0.330 57.9 1.24 (0.62, 2.45) 0.543
Ever conducted CD4 test
Yes 56.7 1.00 56.0 1.00
No 46.7 0.67 (0.31, 1.42) 0.294 26.7 0.29 (0.12, 0.66) 0.004
CD4 count
< = 350 55.1 1.00 55.1 1.00
>350 57.9 1.12 (0.70, 1.79) 0.632 56.7 1.07 (0.67, 1.70) 0.787
Disclosure to RP
Have disclosed to all 55.0 1.00 51.9 1.00
Have disclosed to some 58.2 1.14 (0.63, 2.07) 0.671 52.2 1.01 (0.56, 1.83) 0.968
Have disclosed to none 55.2 1.01 (0.61, 1.65) 0.979 55.2 1.14 (0.70, 1.87) 0.602
Disclosure to NRP
Have disclosed to all 53.8 1.00 46.2 1.00
Have disclosed to some 61.1 1.35 (0.65, 2.80) 0.426 53.7 1.35 (0.66, 2.79) 0.413
Have disclosed to none 55.0 1.05 (0.60, 1.83) 0.876 55.4 1.45 (0.83, 2.54) 0.193
Disclosure to female sex partners
Have no female sexual partners 53.6 1.00 54.0 1.00
Have disclosed to all 47.4 0.78 (0.31, 1.99) 0.604 47.4 0.77 (0.30, 1.96) 0.579
Have disclosed to some 71.4 2.17 (0.66, 7.11) 0.201 57.1 1.14 (0.38, 3.38) 0.817
Have disclosed to none 65.3 1.63 (0.86, 3.10) 0.134 51.0 0.89 (0.48, 1.64) 0.706
Self-perceived health
Very poor/poor 91.7 1.00 75.0 1.00
Fair/good/very good 52.9 0.10 (0.02, 0.44) 0.002 51.5 0.35 (0.14, 0.92) 0.033
Table 3. Association between psychological factors and depression/anxiety.
Dependent variable: Depression Dependent variable: Anxiety
Univariate logistic regression Adjusted logistic regression*
Univariate logistic
regression
Adjusted logistic
regression^
OR
u
(95%CI) pvalue OR
a
(95%CI) pvalue OR
u
(95%CI) pvalue OR
a
(95%CI) pvalue
Positive psychological factor
Gratitude 0.90 (0.86, 0.94) <0.001 0.90 (0.86, 0.94) <0.001 0.95 (0.91, 0.98) 0.005 0.95 (0.91, 0.99) 0.008
Negative psychological factors
Stress 1.17 (1.12, 1.22) <0.001 1.17 (1.12, 1.22) <0.001 1.18 (1.14, 1.24) <0.001 1.19 (1.14, 1.24) <0.001
Enacted stigma
Rarely/never 1.00 1.00 1.00 1.00
Frequently/sometimes 8.59 (2.55, 28.89) 0.001 7.72 (2.27, 26.25) 0.001 2.31 (1.03, 5.19) 0.042 2.07 (0.90, 4.75) 0.088
468 J. LI ET AL

and disclosing their HIV status to doctors (Hassan &
Wahsheh, 2011), it may hinder detection and treatment
of depression. Enacted stigma experienced by HIVMSM
often involves health professionals (Nostlinger, Rojas
Castro, Platteau, Dias, & Le Gall, 2014). Training for ser-
vice providers is required. Perceived HIV-related stress
was associated with depression/anxiety. Effective stress-
reduction programs such as mindfulness (Duncan
et al., 2012) and group stress management training
(Hemmati Sabet, Khalatbari, Abbas Ghorbani, Haghighi,
& Ahmadpanah, 2013) exist, and should be offered to
HIVMSM in China.
Unlike a previous study (Krause, 2009), gratitude did
not moderate the association between perceived stress
and probable depression, implying that the strength
of the association did not vary according to level of
gratitude. Such buffering effects might depend on
type/severity of stressful experiences (Krause, 2009).
Gratitude’s moderation for the association between
enacted stigma and depression was also non-significant.
Further research on similar buffering effects is warranted.
This study’s limitations include inability to establish
causality due to its cross-sectional design, potential selec-
tion bias and limited sampling representativeness due to
non-contacts and refusals, inability to generalize the
findings to other parts of China, potential reporting
biases due to social desirability, and the use of measure-
ments that were not validated.
In sum, HIVMSM in China had poor mental health.
Gratitude was protective, while stress and stigma were
risk factors of depression and anxiety. Gratitude did
not buffer the associations between the two risk factors
and depression/anxiety. Interventions need to modify
both protective and risk factors. It is warranted to com-
pare factors of mental health problems among HIVMSM
and MSM/PLWH in general.
Acknowledgements
We would like to thank all participants who have been
involved in this study and all research assistants for their sup-
port in data collection.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
The study was supported by Lifespan/Tufts/Brown Center for
AIDS Research under a 2013 international developmental
grant [P30AI042853] and by the National Natural Science
Foundation of China under a young scientists’grant
[81302479].
ORCID
Jinghua Li http://orcid.org/0000-0002-4699-1650
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