The primary purpose of this study was to measure HIV-related risk behavior among adults with a SPMI. More than two-thirds of adults in our sample were sexually active and/or involved in injection drug use during the past year. A sizable proportion of patients reported a history of STDs, multiple sexual partners, and/or involvement with high-risk partners, practices that increase risk for HIV infection. Sexual encounters often followed alcohol use or occurred in coercive relationships, contexts associated with enhanced risk for infection. These findings add to the growing body of evidence that (a) contradicts the “prevailing stereotype that they [persons with a SPMI] are asexual or not interested in sex” (Harvey & Trivelli, 1990), and (b) documents that risk among adults who have a SPMI exceeds that found in the general population (cf. Leigh, Temple, & Trocki, 1993
The second purpose of this research was to investigate the antecedents of risky behavior. Guided by the IMB model of HIV-preventive behavior, we measured the hypothesized antecedents of HIV-related behavior. Consistent with this model, many participants were misinformed regarding HIV transmission and prevention. The poor knowledge demonstrated by our patients differs from findings obtained with the general public (Peruga & Celentano, 1993
), where knowledge levels regarding HIV transmission and risk reduction tend to be high. These findings indicate the need for continued education among adults with a SPMI.
Motivational indices indicated that patients are not opposed to condom use and peer influences tend to be favorable; however, they perceive themselves at relatively low risk for infection. If we give greater weight to the latter, a more primary index of motivation, we are left to infer that patients are not motivated to use condoms nor to practice safer sex. The tendency to deny one’s own risk relative to others has been described as “unrealistic optimism.” Weinstein (1984)
has reported that most people demonstrate a bias in their judgments regarding susceptibility to disease or illness; specifically, most people think that they are less likely than the average person to experience problems. Given the high rate of risk behavior and situations observed among adults with a SPMI, we believe that their misperception of risk is more dangerous than that found in the general population.
Participants indicated only modest levels of self-efficacy regarding behavioral skills in situations involving sexual risk. These findings suggest that these individuals may have limited interpersonal skills and/or lack of confidence to use those skills, and may also have difficulty gauging their ability to successfully navigate sexual situations.
Thus, participants in the current study, who were involved in a relatively high level of risk behaviors and situations, can be characterized as lacking key informational, motivational, and self-efficacy requisites needed to reduce their risk of HIV infection. Exploratory analyses documented that adults with a SPMI have an inadequate understanding of the relationship between their behavior and their risk for infection.
In addition to the antecedents identified by the IMB model, other psychological and social characteristics may increase the risk of HIV infection among adults with a SPMI. First, these individuals tend to be economically and socially disadvantaged with less access to health care and, perhaps, to condoms. Second, they may see AIDS as only one of a number of life-threatening problems and one which is less immediate than other concerns (e.g., violence). Third, adults with a SPMI may be vulnerable to illness-related changes in sexual behavior (e.g., hypersexuality), difficulties with judgment and problem-solving, exploitive or unstable social relationships, and co-occurring substance use disorders. Finally, they may be less inclined to insist upon condom use, which could jeopardize relationships that meet essential intimacy or other needs.
Several limitations of this research should be acknowledged. First, it is prudent to question the validity of self-reported behavior. However, we are inclined to trust these findings because evidence suggests that the primary problem in HIV risk assessment is under-reporting rather than over-reporting (Locke et al., 1992
). Second, our operationalization of the constructs proposed by Fisher and Fisher (1992)
was constrained due to the cognitive limitations and decreased stamina associated with having a major mental disorder. Finally, sample size limited the statistical power to examine risk behavior by psychiatric diagnosis, functional status, age, or other potentially predictive variables.
We conclude by recommending that sexual history taking, HIV education, and risk-reduction counseling become an integral component of the care of adults with a SPMI. Guidelines for the provision of these services can be found in Carey et al. (1995)
, Kalichman (1995)
, and Kelly (1995)