Full text of DOI:10.1046/j.1440-1614.2001.00867.x

Risk factors for HIV/AIDS and hepatitis C among
the chronic mentally ill
Sandra Davidson, Fiona Judd, Damien Jolley, Barbara Hocking,
Sandra Thompson, Brendan Hyland
Objective: The objective of this study was to document the prevalence of risk factors for
HIV/AIDS and hepatitis C among people with chronic mental illness treated in a community
setting.
Method: 234 patients attending four community mental health clinics in the North-western
Health Care Network in Melbourne, Australia, completed an interviewer-administered ques-
tionnaire which covered demographics, risk behaviour and psychiatric diagnosis.
Results: The sample was 58% male, and 79% of the sample had a primary diagnosis of
schizophrenia. Forty-three per cent of mentally ill men and 51% of mentally ill women in the
survey had been sexually active in the 12 months preceding the survey. One-fifth of men-
tally ill men and 57% of mentally ill women who had sex with casual partners never used
condoms. People with mental illness were eight times more likely than the general popula-
tion to have ever injected illicit drugs and the mentally ill had a lifetime prevalence of sharing
needles of 7.4%.
Conclusions: The prevalence of risk behaviours among the study group indicate that
people with chronic mental illness should be regarded as a high-risk group for HIV/AIDS
and hepatitis C. It is essential that adequate resources and strategies are targeted to the
mentally ill as they are for other high-risk groups.
Key words: hepatitis C, HIV, mental illness, prevalence, risk behaviour.
Australian and New Zealand Journal of Psychiatry 2001; 35:203–209
In Australia, the predominate mode of transmission for
HIV infection has been same-sex intercourse between
males [1]. More than 85% of HIV transmissions are esti-
mated to have occurred via male homosexual/bisexual
sexual contact [1]. The preponderance of gay men among
people who are HIV positive has resulted in the relative
neglect of other subgroups who may be at high risk of
HIV, such as the chronic mentally ill [2].
Although numerous studies [3–6] have found that the
prevalence of HIV is much higher among people with
chronic mental illness than among the general popu-
lation, other studies have found that HIV risk among
Sandra Davidson, Research Fellow
Barbara Hocking, Executive Director
SANE Australia, Melbourne, Australia
Sandra Thompson, Research Associate
Department of General Practice, Monash University, Melbourne,
Australia
Fiona Judd, Professor, Department of Psychological Medicine, Monash
University, Melbourne, Australia, and Professorial Fellow (Correspondence)
MacFarlane Burnett Centre for Medical Research, Melbourne,
Australia
Department of Psychiatry, University of Melbourne. Address for corres-
pondence: Centre for Rural Mental Health, Bendigo Health Care
Group, Bendigo, Australia. Address for correspondence: PO Box 126,
Bendigo, Victoria 3552, Australia. Email: f.judd@bendigohealth.org.au
Brendan Hyland, Consultant Psychiatrist
Bendigo Health Care Group, Bendigo, Australia
Damien Jolley, Associate Professor of Biostatistics and Epidemiology
Department of Health Sciences, Deakin University, Melbourne,
Australia
Received 14 July 2000; revised 11 October 2000; accepted 18 October
2000.

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RISK FACTORS FOR HIV/AIDS AND HEPATITIS C
North-western Health Care Network Mental Health Program were
interviewed about their health behaviour and underwent a brief phys-
ical examination. Participants were asked about a range of health
behaviours including those related to preventive service use and car-
diovascular risk [9]. This paper will report the results related to risk of
HIV and HCV.
mentally ill patients is often neglected by mental health
practitioners [7]. Thompson et al. [7] found high rates of
risk behaviour among psychiatric patients yet only 16%
of patients had ever had anyone talk to them specifically
about HIV and its transmission.
The majority of prevalence studies of HIV in psychi-
atric populations have emanated from the USA, and have
estimated an HIV seroprevalence ranging from 4% to
23% [4]. Prevalence data from other countries, including
Australia, are limited. However, one Australian report
has estimated a HIV seroprevalence of 1–5% for people
attending the Sydney Inner City Mental Health Service
[8]. In contrast, the seroprevalence rate for the Australian
community is less than 0.1%.
The higher risk for HIV transmission among the men-
tally ill is due to a combination of psychiatric symptoms
leading to risk behaviours and associated problems of sub-
stance abuse, as well as social and interpersonal difficul-
ties. For example, in patients with bipolar mood disorder,
mania may lead to increased sexual drive and increased
high-risk behaviours. People with depression often have
poor self-care, while individuals with chronic schizo-
phrenia may have poor planning and poor judgement.
The study by Thompson et al. [7] documented the preva-
lence of risk factors for HIV infection among people with
chronic mental illness in an Australian setting. They found
that people with mental illness were more likely than the
general population to have a history of injecting drug use
(IDU) and to report having sex with a prostitute in the past
year. Almost 10% of men with mental illness had had anal
sex with another man and 19% of women had had sex with
a bisexual man. The mentally ill were also highly likely
to have had multiple sexual partners in the past year.
High rates of injecting drug use (IDU) among people with
mental illness also puts them at risk of infection with the
hepatitis C virus (HCV). The HCV has become the most
commonly reported notifiable infection in Australia [1]
and has serious physical health consequences.
People with psychiatric disorders who are infected with
HIV account for a disproportionate amount of time and
resources in case management, welfare and support ser-
vices.Yet, to our knowledge, the study by Thompson et al.
is the only published Australian study on this subject.
The current study was designed to extend the work
of Thompson et al. [7] and document the prevalence of
sexual behaviour and drug-taking practices that are known
risk factors for the transmission of HIV and HCV among
people attending community mental health services.
A 10-item measure of sexual behaviour was adapted from the scale
developed by Volavka et al. [10]. The scale included items on the
number of sexual partners in the past 12 months, the incidence of
homosexual sex, sex with high-risk partners and use of condoms
during sex. Additional items on this measure distinguished between
condom use with casual partners and regular partners.
Information on illicit drug use was obtained using a seven-item
instrument adapted from the 1995 National Drug Strategy Household
Survey [11]. This measure examines the use of a range of illicit drugs
over the previous 12-month period and includes items on injecting drug
use and sharing needles.
Only patients judged by clinic staff to be capable of giving informed
consent were approached for interview. The majority of participants
were recruited into the study via their case manager or they were
approached at the clinic by the researcher who explained the aims
and requirements of the study. A small number of participants were
recruited when they contacted the researcher after seeing notices in the
clinic advertising the project. Patients were excluded from participa-
tion if they were judged by their case manager to be too unwell; were
unable to understand the concept of informed consent; were unable to
speak English and an interpreter was not available; or were unwilling
to participate.
Patients who provided their informed consent to participate in the
study were interviewed in a private room at the clinic where they
received mental health services. Confidentiality was assured and
patient responses were only identified by a number code. Approval for
the study was obtained from the Research and Ethics Committee of the
North-western Health Care Network.
Analysis
Data were entered into SPSS (SPSS, Chicago, IL, USA) and descriptive
analysis was conducted. Odds ratios and confidence intervals (95% CI)
were calculated to estimate the differences in the prevalence of risk
factors between people with mental illness and the general Australian
population. Data on sexual risk factors among people with mental illness
were compared, where possible, with data from an Australian population-
based study of the prevalence of HIV risk behaviours conducted by
Ross [12]. Data on illicit drug use among the mentally ill was com-
pared with data on the general population provided by the most recent
Drug Strategy Household Survey, released in 1999 [11]. Five partici-
pants under 20 years of age in the current study were excluded from
analysis as they did not constitute a large enough group to compare with
the under-20 sample from the National Drug Survey [11].
Results
Method
Sample
The methods used in this study have been described elsewhere [9].
Briefly, 234 outpatients of four Area Mental Health Services in the
The study sample consisted of 97 women and 132 men (n = 229)
between the ages of 20–65 years who were living with chronic mental

S. DAVIDSON, F. JUDD, D. JOLLEY, B. HOCKING, S. THOMPSON, B. HYLAND
205
illness. The majority (79%) of the sample had a primary diagnosis
of psychotic disorder, followed by major depressive disorder (9%),
bipolar disorder (4%), personality disorder (4%), and other disorders
(3%). More than half (51%) had been hospitalized for psychiatric
illness in the last 12 months, and a further 17% had been hospitalized
in the past 3 years. Twenty per cent of the sample were married or
living in a de facto relationship at the time of interview and just over
half (51%) lived with either their parents or partner and/or children.
Few participants were currently employed and 92% received a govern-
ment pension as their main form of income. Just over one-quarter
(27%) were born in a non-English-speaking country.
Table 1 shows that nearly one-third (32.1%) of mentally ill men and
10% of mentally ill women who were sexually active had multiple
(three or more) partners in the past 12 months. Among the study
sample, men were significantly more likely to have had multiple sexual
partners than women (OR = 2.9, 95% CI = 1.0–8.12).
Both men and women with mental illness were less likely to use
condoms in a primary relationship than a casual relationship (Table 2).
Almost three-quarters (73.5%) of people who were in a regular sexual
relationship never used condoms, while one-fifth (20%) of men and
57% of women who had sex with casual partners never used condoms.
Only 52% of men and 14% of women who had sex with casual part-
ners in the last 12 months always used condoms.
The only data from Ross [12] that can be directly compared with the
current study is on the prevalence of male homosexual sex. Rates of
male-to-male sex among people with mental illness were lower than
reported by Ross [12] for the general population (3.7% cf. 6.1%). Only
1% of women in the current study reported having sex with a bisexual
man in the past 12 months.
Sexual behaviour
Forty-three per cent of mentally ill men reported being sexually
active in the 12 months prior to the study (Table 1). In contrast, 72% of
men in the study by Ross [12] reported that they had heterosexual sex
in the previous 12 months. Just over half (51%) of the women in the
mentally ill sample reported that they had been sexually active com-
pared with 73% of women who reported they had had sex with a male
in the community sample. Ross [12] did not provide overall prevalence
rates on people who were sexually active, but divided the data into four
categories based on the participants’ gender and the gender of their
sexual partner. Therefore, respondents who had sex with both men and
women will be recorded twice in Ross’s tables [12]. Because the rates
of homosexual sex are much lower than the rates of heterosexual sex
we have used Ross’s figures to provide an estimation (albeit an
underestimation because they exclude people who only had sex with
same-sex partners) of the prevalence of sexual activity in the general
population.
Sixteen per cent of men and 9% of women with mental illness
reported that they had had sex in the past year with someone whom
they believed had a lot of other sexual partners. Five per cent of
mentally ill men and 3% of women reported that they had had sex
with an injecting drug user in the last 12 months and one person
reported that they had had sex with someone they knew to be HIV
positive.
Illicit drug use risk factors
Table 3 shows that people with mental illness were much more likely
than a community sample to report that they had used heroin in the pre-
vious 12 months, that they had ever injected illicit drugs and/or that
they had recently injected illicit drugs. The only category for which the
mentally ill recorded a lower prevalence of drug use than the general
population was among women aged 30–39. Mentally ill women in their
30s recorded zero prevalence in terms of recent heroin use and recent
injecting drug use. The higher lifetime prevalence of women with
Among the mentally ill, 19% of men and 43% of women reported
being sexually active within a primary relationship, while 29% of men
and 14% of women reported being sexually active with casual partners
in the last 12 months. Five per cent of men and six per cent of women
had both primary and casual partners during this time and are counted
in each category.
Table 1. Sexual behaviour in psychiatric outpatients
Male (%)
n = 132
Female (%)
n = 97
Total (%)
n = 229
Number of partners 12 months
None
One
Two
57.4
20.6
7.4
49.0
39.8
6.1
53.8
28.6
6.8
Three to five
Six to 10
More than 10
Refused to answer
Total
11.8
0.7
0.7
1.5
100.0
2.0
2.0
1.0
ND
7.7
1.3
0.9
0.9
100.0
100.0
Male-to-male sex
Refused to answer
3.7
1.5
ND
ND
ND
ND
Female sex with bisexual man
ND, no data.
ND
1.0
ND

206
RISK FACTORS FOR HIV/AIDS AND HEPATITIS C
Table 2. Condom use with primary and casual partners among psychiatric outpatients
Male (%)
n = 132
Female (%)
n = 97
Total (%)
n = 229
Used condoms with primary partner
Never
14.0
1.5
0.7
31.6
5.1
1.0
21.4
3.0
0.9
Less than half the time
More than half the time
Always
1.5
5.1
3.0
Refused to answer
Not applicable*
Total
1.5
80.9
100.0
ND
57.1
100.0
0.9
70.9
100.0
Used condoms with casual partner
Never
Less than half the time
More than half the time
Always
5.9
3.7
2.9
15.4
1.5
70.6
100.0
8.2
1.0
3.1
2.0
ND
6.8
2.6
3.0
9.8
0.9
Refused to answer
Not applicable†
85.7
100.0
76.9
100.0
Total
*Either because not sexually active or did not have sex with a primary partner. †Either because not sexually active or did not have
sex with a casual partner. ND, no data.
Table 3. Prevalence (%) of heroin and injecting drug use for a mentally ill sample and the 1998
National Drug Strategy Household Survey
Mentally ill
Females
General population
Females
Males
Total
Male
Total
OR
95% CI
Recent heroin use
20–29
30–39
9.1
6.8
3.6
6.1
9.5
0.0
2.6
3.1
9.3
3.7
3.2
4.8
2.9
0.7
0.4
1.0
1.3
0.3
0.1
0.5
2.1
0.5
0.3
0.7
4.8
7.6
11.0
7.1
1.9–12.0
2.4–24.3
3.4–35.2
3.9–13.0
40+
All ages
Ever injected
20–29
30–39
40+
All ages
Recently injected
20–29
30–39
40+
All ages
Ever shared needles
20–29
30–39
40+
All ages
Shared recently
20–29
30–39
40+
21.9
14.0
10.9
14.6
23.8
5.3
15.8
13.4
22.6
9.9
12.9
14.1
6.5
4.1
1.3
2.8
2.9
1.7
0.3
1.3
4.7
2.9
0.8
2.1
5.9
3.7
18.4
7.7
3.1–11.2
1.8–7.8
10.2–33.1
5.1–11.6
12.1
6.8
3.6
14.3
0.0
2.6
13.0
3.7
3.2
3.0
0.9
0.4
1.0
1.1
0.3
< 0.1
0.4
2.1
0.6
0.2
0.7
7.0
6.4
16.5
8.6
3.2–15.4
2.0–20.5
5.2–52.8
4.8–15.5
6.8
4.1
5.7
9.1
6.8
7.3
7.6
14.3
2.6
7.9
11.1
4.9
7.5
7.4
7.2
6.0
2.3
1.8
2.3
9.5
0.0
0.0
2.1
7.5
1.2
1.1
2.2
All ages

S. DAVIDSON, F. JUDD, D. JOLLEY, B. HOCKING, S. THOMPSON, B. HYLAND
207
mental illness injecting illicit drugs was not significant (OR = 3.2, 95%
CI = 0.24–13.1).
not differentiate between primary and casual sexual part-
ners. These discrepancies in data collection, together with
the lengthy time period between the two studies, imposes
some limitation on comparisons between the mentally ill
in the current sample and the general population in the
study by Ross [12].
Although people with chronic mental illness in this
study are less likely to be sexually active than people in
the general population, almost half of the study sample
had been sexually active in the 12 months prior to the
interview. It has been suggested that the mentally ill are
asexual [13], and this belief may have contributed to
the lack of attention within mental health settings to HIV
risk among psychiatric patients. However, the results
of this study are consistent with a previous study by
Cournos et al. [14]: both clearly show that sexual activ-
ity is prevalent among the mentally ill.
The sexual relationships of mentally ill men were char-
acterized by a high prevalence of casual sexual partners.
Although women were more likely to be in a sexual rela-
tionship with a primary partner than were men, 14% of
women also reported having casual sexual partners in the
previous year. Among people who were sexually active,
one-third of men and 10% of women with mental illness
had more than three sexual partners over the last year.
This small group of psychiatric patients are at increased
risk of HIV or other sexually transmitted disease infec-
tion because as the number of sexual partners increases,
risk of exposure to infection also increases. The rate of
casual sex among the mentally ill highlights the impor-
tance of mental health workers taking a full sexual history
from patients in order to identify those patients at risk.
Unlike other studies on the prevalence of HIV risk
factors, this study distinguished between casual and pri-
mary partners and examined the use of condoms [7,12].
This distinction revealed that only 14% of mentally ill
women who had sex with casual partners always used
condoms.
People with mental illness were seven times more likely than the
general population to report using heroin in the last 12 months
(OR = 7.1, 95% CI = 3.9–13.0). The mentally ill were almost eight
times more likely to report having ever injected illicit drugs (OR = 7.7,
95% CI = 5.1–11.1) and 8.5 times more likely to report injecting illicit
drugs in the previous 12 months (OR = 8.6, 95% CI = 4.8–15.5).
The highest rates of heroin and injecting drug use for both men and
women occurred in the 20–29 age group for both the general popula-
tion and among the mentally ill.
For men, there was an inverse relationship between the prevalence of
drug-related risk factors for HIV and age. This relationship was also
true for women in the general population, but not for women with
mental illness, due to the low prevalence of IDU among women
between 30 and 39 years. With the exception of mentally ill women
between 30 and 39, there was a decline in drug-related behaviour with
increasing age.
There is no comparative data available from the 1998 National Drug
Strategy Household Survey [11] in relation to sharing needles or other
injecting equipment. The lifetime prevalence of people with mental
illness ever sharing needles was 7.4%. Prevalence rates were highest in
the youngest age group and were higher in women than men. Nine per
cent of males and 14% of females between 20 and 29 years reported
sharing needles at least once. Although only 2% of the overall sample
reported sharing needles in the past 12 months, 6% of young men and
almost 10% of young women had shared needles recently.
Testing
More than one-third (36.8%) of people with mental illness reported
that they had been tested for HIV antibodies. A substantial proportion
(12%) did not know whether or not they had undergone a HIV antibody
test. People who had ever injected illicit drugs were significantly more
likely to have had an HIV test than people who had never injected
(OR = 6.6, 95% CI = 2.5–17.2). One-quarter of participants reported
that they had been tested for HCV. One-fifth (21.4%) of patients had
not heard of hepatitis C and did not know if they had been tested.
Patients who had ever injected illicit drugs were significantly more
likely to report that they had been tested for hepatitis C (OR = 9.6, 95%
CI = 3.8–24.0).
The major mode of HIV transmission among women
in Australia has been via sex with high-risk men [15].
Although only a small proportion of women reported
having sex with high-risk men it is highly likely that
women with multiple casual partners are unaware of either
the sexual history or seroprevalence status of casual part-
ners. Therefore, the proportion of women who had sex
with high-risk (IDU or bisexual) men was probably
grossly underreported in this study. The high prevalence
of unprotected sex with casual partners reflects the sexual
vulnerability of women with mental illness and suggests
that women with mental illness may be at even greater
risk of HIV than their male counterparts. The sexual vul-
nerability of women with mental illness is underscored
by studies such as that conducted by Coverdale and
Discussion
The difficulties in conducting sensitive research on
sexual behaviour is demonstrated by the paucity of studies
in the area. Studies of sexual behaviour are typically con-
fined to special subgroups such as gay men or secondary
school students and large-scale, population-based studies
are limited. The 1988 study conducted by Ross [12] pro-
vides the only Australian population-based data available
for comparison. Ross [12] reported prevalence rates for
risk factors, such as homosexual sex for both men and
women, and sex with a prostitute. However, Ross [12] did
not collect other information on prevalence of multiple
sexual partners or the use of condoms. Moreover, he did

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RISK FACTORS FOR HIV/AIDS AND HEPATITIS C
Turbott [16] which found that mentally ill women were
significantly more likely to be sexually abused or coerced
into sex than women in the general community and men-
tally ill men. Because the current study did not collect
information regarding whether sex was consensual or
coerced it is possible that women who were forced into
non-consensual sex did not report themselves as sexually
active, thus underestimating the real prevalence of sexual
encounters and the subsequent risk of HIV and hepatitis C.
A lower prevalence of male-to-male sex in the past
12 months was reported in this study than in the studies
by Ross [12] or Thompson et al. [7]. In an attempt to
reduce recall bias patients were only asked about their
sexual history for the past year. If patients were asked
about male-to-male sex in the last 10 years, as did the
study by Thompson et al. [7], the prevalence rate would
probably have been higher. Given that over half of the
sample had been hospitalized for psychiatric illness in
the preceding 12 months, and 79% had a primary diag-
nosis of schizophrenia, it is reasonable to assume that the
opportunity for sexual relations was limited by being
acutely ill. Unlike mania, psychotic episodes are not
generally a cause of increased sexual activity. On this
basis, it is possible that the lifetime prevalence of male-
to-male sex among the mentally ill sample is equivalent
to Thompson et al. [7] which was around 13%. However,
the low proportion of men in the study admitting to
male-to-male sex indicates the difficulty of evaluating
effectiveness of interventions for this high-risk behav-
iour. It is recommended that future studies include items
on both current and past sexual behaviour.
People with chronic mental illness in this study were
much more likely to use heroin than other people and
they were also much more likely to have a history of
IDU. It is of major concern that 13% of young people
(20–29 years) with mental illness had injected illicit
drugs in the 12 months before the interview. Injecting
drug use is the second major route of HIV transmission
in Australia and accounts for around 8% of cases, although
approximately half of these were men who also had a
history of sex with other men [1]. Injecting drug use is
also a primary route of transmission for HCV [1]. Fifty
per cent of people attending needle and syringe exchange
programs in Australia in 1998 had the HCV. Epidemio-
logical data shows that HCV prevalence among people
who had injected drugs for less than 3 years was 20%.
This rose to over 60% for people who had injected for
more than 6 years [1].
with a wide body of literature showing that substance use
is much higher among the mentally ill [17,18]. Although
it is recognized that drug use is prevalent in people with
chronic mental illness, attention is usually concentrated
on how substance use impacts on psychiatric symptoms
and less attention is given to how it may affect their
physical health. This study demonstrates that neglecting
this latter relationship places the chronically mentally ill
IDU at great risk of both HCV and to a lesser extent
HIV/AIDS.
The prevalence of heroin and IDU among people with
chronic mental illness is likely to increase as patients cur-
rently in their 20s with high drug exposure move into the
older age groups and are replaced by a younger cohort for
whom acceptability of and access to recreational drugs
also increases. Continual increases in the prevalence of
intravenous drug use may ultimately force us to reconsider
what are normal levels of IDU. If such projections are
realized there will be an increased need for education, pre-
ventative interventions and treatment of the mentally ill
for physical diseases transmitted through IDU.
In their 1995 article, ‘Psychiatric patients and HIV
infection: a new population at risk?’ Stefan and Catalan
[3] noted an increased prevalence of HIV infection
among psychiatric patients compared with the general
population. Stefan and Catalan [3] suggested that issues
relating to HIV/AIDS are likely to assume increased
importance in psychiatric practice in the future. The
current study supports their warning and the suggestion
that the chronic mentally ill should be regarded as a
high-risk group for HIV infection. Furthermore, the
alarming rates of IDU shown in this cohort illustrates
that concern should not be limited to HIV/AIDS, but
extended to HCV. It is essential that adequate resources
and strategies are targeted to the mentally ill as they are
for other high-risk groups.
Acknowledgements
The authors are grateful for the support of the
Managers, staff and clients of the four Area Mental
Health Services who participated in this project. The
study was funded by a project grant from the Victorian
Health Promotion Foundation.
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