Making the link between mental health and condom use
Indian trial that offered men who have sex with men resilience counselling saw unprotected sex drop – but new HIV and STI infections remained high.
An India trial that provided men who have sex with men with counselling to build mental resilience and self-esteem found it led to a reduction in condomless sex but did not reduce HIV and sexually transmitted infections (STIs).
Around 600 men who have sex with men from Chennai and Mumbai were recruited between 2015 and 2018 then followed for 12 months (the trial ended in 2019).
Half the men received standard counselling and testing for HIV and STIs. The other half received standard HIV/STI counselling and testing plus “resilience-based psychosocial counselling”, consisting of four group sessions and six individual sessions.
The group sessions were led by a counsellor and a peer and covered topics including self-worth, self-acceptance, tackling isolation, dealing with challenging situations relating to sexual orientation, personal safety, alcohol and substance misuse and risk-reduction skills. Individual sessions focused on self-esteem, coming out experiences, sexual risk limits, risk reduction, problem solving and personal goals.
Around 85% of men remained in the study after 12 months. Around 85% in the intervention group attended at least half of the individual counselling sessions and 73% attended at least half of the group sessions.
On joining the study, participants reported having condomless anal sex a mean of eight times in the past month. One in ten participants were living with HIV and one third had at least one STI.
Men in both groups reduced condomless anal sex during the trial, but the decline was far greater among men who had resilience counselling. The reduction in condomless anal sex was 56% greater in the intervention group compared to the control group at 4 months, and 72% greater at 8 and 12 months.
The resilience counselling was found to significantly reduce depression and improve self-esteem over time, both of which were associated with a reduction in condomless sex.
But despite the reduction in unprotected sex, new HIV and STI infections remained high, with 23% of participant getting a new STI during the trial and 4% contracting HIV. There was no difference in STI incidence between the intervention and the control group. In Chennai, HIV incidence was much lower in the intervention group, but in Mumbai there was no difference between the two groups.
The findings show that resilience counselling has the potential to both improve the mental health of Indian men who have sex with men and also reduce the key HIV risk behaviour of condomless anal sex.
But the continued high levels of STIs and HIV incidence suggest that resilience counselling alone will not be enough to prevent new infections.
If PrEP becomes more widely used by men who have sex with men in India, it may help to reduce HIV infections among this group, but it will not reduce STIs. Increasing condom use further and addressing other risk behaviours, such as multiple sexual partnerships, will be vital.
The study’s authors said: “From the perspective of mental health and quality of life, these are important findings, especially given the evidence of disproportionately high levels of mental health distress seen in this disenfranchised and often hidden and overlooked population.
“However, from an HIV and STI prevention perspective, the absence of a significant difference in incidence…in this population [is] concerning.”
A cost-effectiveness analysis of the resilience counselling is due to be published soon. This will help to determine whether it should be introduced across India.