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Opposing associations of depression with sexual behaviour: implications for epidemiological investigation among gay, bisexual and other men who have sex with men
  1. Ada R Miltz1,
  2. Alison J Rodger1,
  3. Andrew N Phillips1,
  4. Janey Sewell1,
  5. Simon Edwards2,
  6. Sris Allan3,
  7. Lorraine Sherr1,
  8. Anne M Johnson1,
  9. William J Burman4,
  10. Fiona C Lampe1
  11. ASTRA and AURAH Study Groups
    1. 1Institute for Global Health, University College London, London, UK
    2. 2Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
    3. 3City of Coventry NHS Healthcare Centre, Coventry, UK
    4. 4Denver Public Health, Denver, Colorado, USA
    1. Correspondence to Dr Ada R Miltz, Institute for Global Health, University College London, London NW3 2QG, UK; Ada.Miltz.11{at}


    Objective The aim of this report is to investigate the nature of the relationship between depression and condomless sex (CLS) among gay, bisexual and other men who have sex with men (GBMSM).

    Methods Data are from the Antiretrovirals, Sexual Transmission Risk and Attitude (ASTRA) study of people living with HIV and attending one of eight HIV outpatient clinics in England (2011–2012) and the Attitudes to and Understanding of Risk of Acquisition of HIV (AURAH) study of HIV-negative/unknown status individuals attending one of 20 genitourinary medicine clinics in England (2013–2014). This analysis included GBMSM only. For each study, the prevalence of depressive symptoms (Patient Health Questionnaire-9 score ≥10) was presented according to three categories of sex in the past 3 months (considering anal/vaginal sex with men/women and anal sex with men in separate definitions): (1) no sex, (2) condom-protected sex only and (3) CLS. Multinomial logistic regression with ‘condom-protected sex only’ as the reference group was used to adjust for age and (for ASTRA participants) time since HIV diagnosis.

    Results There were opposing associations of depression with recent sexual behaviour: the prevalence of depression was higher among those who reported no sex and those who reported CLS, compared with those who reported condom-protected sex only. Among the 2170 HIV-positive GBMSM in ASTRA, considering anal/vaginal sex with men/women, the prevalence of depressive symptoms was 32%, 20% and 28%, respectively, among men reporting no sex (n=783), condom-protected sex only (n=551) and CLS (n=836) (global p<0.001). Among the 1477 HIV-negative GBMSM in AURAH, the prevalence of depressive symptoms was 12%, 8% and 13%, respectively, for no sex (n=137), condom-protected sex only (n=487) and CLS (n=853) (global p=0.017). Patterns were similar after adjustment and when only considering anal sex between men.

    Conclusions Depression may be linked both to lack of sexual activity and to sexual risk taking. When investigating associations between depression and CLS, it is important to separate out individuals reporting condom-protected sex only from those reporting no sex.

    • epidemiology (general)
    • gay men
    • HIV
    • sexual behaviour
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    • Handling editor Jane S Hocking

    • Collaborators The ASTRA Study Group: Fiona Lampe, Alison Rodger, Andrew Speakman, Andrew Phillips, Marina Daskalopoulou, Lorraine Sherr, Simon Collins, Jonathan Elford, Alec Miners, Anne Johnson, Graham Hart, Anna-Maria Geretti and Bill Burman. ASTRA clinic teams: Alison Rodger, Margaret Johnson, Jeff McDonnell, Adebiyi Aderonke (Royal Free Hospital), Richard Gilson, Simon Edwards, Lewis Haddow, Simon Gilson, Christina Broussard, Robert Pralat, Sonali Wayal (Mortimer Market Centre), Martin Fisher, Nicky Perry, Alex Pollard, Serge Fedele, Louise Kerr, Lisa Heald, Wendy Hadley, Kerry Hobbs, Julia Williams, Elaney Youssef, Celia Richardson, Sean Groth (Brighton and Sussex University Hospitals), Ed Wilkins, Yvonne Clowes, Jennifer Cullie, Cynthia Murphy, Christina Martin, Valerie George, Andrew Thompson (North Manchester General Hospital), Jane Anderson, Sifiso Mguni, Damilola Awosika, Rosalind Scourse (Homerton University Hospital), Kazeem Aderogba, Caron Osborne, Sue Cross, Jacqueline Whinney, Martin Jones (East Sussex Sexual Health Clinic), Rebecca O’Connell, Cheryl Tawana (Newham University Hospital), Monica Lascar, Zandile Maseko, Gemma Townsend, Vera Theodore, Jas Sagoo (Whipps Cross University Hospital). The AURAH Study Group: Alison J Rodger, Andrew Speakman, Fiona C Lampe, Andrew N Phillips, Janey Sewell, Ada R Miltz, Lorraine Sherr, Richard J Gilson, David Asboe, Nneka C Nwokolo, Amanda Clarke, Mark M Gompels, Sris Allan, Simon Collins, Christopher Scott, Sara Day, Martin Fisher, Jane Anderson, Rebecca O’Connell, Monica Lascar, Vanessa Apea, Maneh Farazmand, Susan Mann, Jyoti Dhar, Daniel R Ivens, Tariq Sadiq, Stephen Taylor, Michael Brady, Alan Tang, Rageshri Dhairyawan, Graham J Hart, Anne M Johnson, Alec Miners and Jonathan Elford. AURAH clinic teams: Rageshri Dhairyawan, Sharmin Obeyesekera (Barking), Vanessa Apea, John Saunders, James Hand, Nyasha Makoka (Barts and the London), Stephen Taylor, Gerry Gilleran, Cathy Stretton (Birmingham), Martin Fisher, Amanda Clarke, Nicky Perry, Elaney Youssef, Celia Richardson, Louise Kerr, Mark Roche, David Stacey, Sarah Kirk (Brighton), Mark Gompels, Louise Jennings, Caroline Holder, Katie Anne Baker (Bristol), Maneh Farazmand, Matthew Robinson, Emma Street (Calderdale & Huddersfield), Sris Allan, Abayomi Shomoye (Coventry), Nneka Nwokolo, Ali Ogilvy (56 Dean Street), Jane Anderson, Sfiso Mguni, Rebecca Clark, Cynthia Sajani, Veronica Espa (Homerton), David Asboe, Sara Day, Ali Ogilvy, Sarah Ladd (John Hunter), Susan Mann, Michael Brady, Jonathan Syred, Lisa Hamza, Lucy Campbell, Emily Wandolo, Janagan Alagarajah (Kings), Linda Mashonganyika, Jyoti Dhar, Sally Batham (Leicester), Richard Gilson, Rita Trombin, Ana Milinkovic, Clare Oakland (Mortimer Market), Rebecca O’Connell, Nyasha Makoka (Newham), Alan Tang, Ruth Wilson, Elizabeth Green, Sheila O’Connor, Sarah Kempster, Katie Keating Fedders (Reading), Daniel Ivens, Nicola Tyrrell, Jemima Rogers, Silvia Belmondo, Manjit Sohal (Royal Free), Tariq Sadiq, Wendy Majewska, Anne Patterson, Olanike Okolo, David Cox, Mariam Tarik, Charlotte Jackson, Jeanette Honigsbaum, Clare Boggon, Simone Ghosh, Bernard Kelly, Renee Aroney (St George’s), Christopher Scott, Ali Ogilvy (West London Centre for Sexual Health), Monica Lascar, Nyasha Makoka, Elias Phiri, Zandile Maseko (Whipps Cross). CAPRA Advisory Board: Sir Nick Partridge, Kay Orton, Anthony Nardone, Ann Sullivan, Lorraine Sherr, Graham Hart, Simon Collins, Anne Johnson, Alec Miners and Jonathan Elford.

    • Contributors FCL and ARM conceived and designed the analysis. ARM drafted the manuscript and conducted all analyses. All authors contributed to data interpretation, writing, revision and approval of the final manuscript.

    • Funding This work was supported by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research funding scheme (RP-PG-0608–10142). The ASTRA and AURAH Study Groups acknowledge the support of the NIHR through the Comprehensive Clinical Research Network.

    • Disclaimer The views expressed in this manuscript are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval The ASTRA study was approved by the North West London REC 2 research ethics committee (10/H0720/70). The AURAH study was approved by the NRES Committee London-Hampstead (13/LO/0246).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available upon reasonable request. We have a number of planned analyses for the ASTRA and AURAH studies, but welcome proposals for additional analysis. Please contact Dr Fiona Lampe ( The Study Core Group will review proposals.

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