Depression, self-efficacy, and sexual behaviour among men who have sex with men Miltz A1, Rodger A1, Sewell J1, Speakman A1, Phillips A1, Sherr L1, Gilson R2, Asboe D3, Nwokolo N4, Clarke A5, Allan S6, Collins S7, Lampe F1, for the AURAH (Attitudes to and Understanding of Risk of Acquisition of HIV) Study Group. 1HIV Epidemiology and Biostatistics Group, Research Department of Infection and Population Health, University College London, London, UK; 2Centre for Sexual Health and HIV Research, Research Department of Infection and Population Health, Mortimer Market Centre, University College London, London, UK; 3John Hunter Clinic, London, UK; 4Dean Street Sexual Health Clinic, London, UK; 5Royal Sussex County Hospital, Brighton, UK; 6City of Coventry Healthcare Centre, Coventry, UK; 7HIV i-Base, London, UK. Introduction The role of depression as a determinant of HIV/STI risk among men who have sex with men (MSM) is poorly understood. Although there is evidence of a link between depressive symptoms and sexual behaviour, the mechanisms by which it operates, and implications for intervention, are uncertain. In the context of one’s sex life, depressive symptoms may lower one’s perceived ability to exercise self-protective control in sexual situations where this is desired. This we call self-efficacy (conceptualized in social cognitive theory) for sexual safety, and here for brevity just refer to as self-efficacy. Material and Methods The Attitudes to and Understanding of Risk of Acquisition of HIV (AURAH) Study is a cross-sectional questionnaire study of HIV-negative individuals attending UK GUM services (2013-2014). Associations between (i) depressive symptoms (score of ≥10 on PHQ-9) and sexual behaviour, (ii) depressive symptoms and self-efficacy, (iii) self-efficacy and sexual behaviour, and (iv) the effect of adjustment for self-efficacy on the association between depressive symptoms and sexual behaviour, were investigated among 1340 gay, bisexual, and other MSM reporting recent sex using modified Poisson regression, adjusted first for socio-demographic factors (age, UK-born, sexual identity, education, relationship, and study region), and then additionally for lifestyle factors (regular smoking, higher risk drinking and number of recreational drugs used). Sexual behaviour included: Measures of condomless sex (CLS) partners in the past three months: (i) any, (ii) ≥2, (iii) unknown/HIV+ status, (iv) receptive unknown status, additional measures of CLS in the past year: (v) STI diagnosis, (vi) PEP use, and measures of high partner numbers: (vii) 11 or more new sexual partners, and (viii) group sex. We defined strong agreement with the statement ‘I feel confident that, if I want to, I can make sure a condom is used with any partner, in any situation’ as indicating high self-efficacy for sexual safety. Difficulty negotiating condom-use was defined as agreement with the statement ‘I find it difficult to discuss condom use with any new sexual partner’. Results (i) The prevalence of depressive symptoms was 12.4% (166/1340). Prevalence of sexual behaviour was 63.7%, 32.1%, 35.4%, 14.0%, 31.6%, 15.5%, 36.0%, and 37.0% for measures (i)-(viii) respectively. Prevalence of high self-efficacy was 67.2%, and 10.6% for difficulty negotiating condom-use. Depressive symptoms were associated with CLS partners, STI diagnosis, and PEP use but not high partner numbers, Figure 1. Results (ii) Adjusted for socio-demographic factors, depressive symptoms were associated with lowered self-efficacy [Adjusted Prevalence Ratio aPR 0.82 95%CI 0.71, 0.94; p=0.006], and difficulty negotiating condom-use [aPR 1.77 95%CI 1.18, 2.63; p=0.005]. Associations remained after additional adjustment for lifestyle factors. Results (iii) High self-efficacy was associated with lower prevalence of CLS partners, STI diagnosis, and PEP use but not high partner numbers, Figure 2. Similar, albeit weaker, associations were found when investigating difficulty negotiating condom-use, Figure 3. Results (iv) Adjusting additionally for self-efficacy measures further attenuated the association between depressive symptoms and CLS partners (including STI diagnosis), Table 1. N=1340 MSM reporting anal/vaginal sex (past 3 months) Figure 1: Unadjusted and adjusted associations of depressive symptoms (PHQ-9≥10) with sexual behaviour Figure 2: Unadjusted and adjusted associations of high self-efficacy for sexual safety with sexual behaviour Figure 3: Unadjusted and adjusted associations of finding it difficult to discuss condom use with sexual behaviour Sexual behaviour measures p value  <0.001 0.002 0.017   <0.001 0.001 0.013 0.004 0.006 0.008 0.009 0.363 0.067 0.397 0.361 0.917 0.106 p value <0.001   0.004 0.013 0.006 0.008 0.018 0.511 0.857 0.687 0.085 0.242 0.815 p value <0.001   0.001 0.003 0.004 0.157 0.068 0.084 0.129 0.052 0.054 0.828 0.800 0.888 0.320 0.370 0.282 (i) Any CLS (past 3 months) (n=853) (ii) CLS with 2+ partners (past 3 months) (n=430) (iii) CLS with unknown/HIV+ partner(s)* (past 3 months) (n=474) (iv) Any receptive CLS with unknown partner (past 3 months) (n=187) (v) Bacterial STI diagnosis (past year) (n=423) (vi) PEP use (past year) (n=207) (vii) 11+ new sexual partners (past year) (n=483) (viii) Group sex (past 3 months) (n=496) *Excludes men who reported one HIV positive long-term CLS partner on ART Unadjusted model [N=1340] Age, UK born, sexuality, university education, relationship status, and study clinic region [N=1316] PR= Prevalence ratio, p value by Wald test Same as above plus smoking, drinking, and recreational drugs [N=1316] Conclusions Depressive symptoms were strongly associated with CLS. Associations remained after additional adjustment for lifestyles factors, suggesting that the association is not primarily due to higher levels of recreational drug (and alcohol) use among those with depressive symptoms. Lowered self-efficacy/difficulty negotiating condom-use may be a mechanism through which depression leads to CLS. Management of depression alongside interventions surrounding self-efficacy/negotiation of condom-use may play an important role in HIV/STI prevention. Table 1: Impact of adjusting for high self-efficacy and difficulty discussing condom use on the relationship between depressive symptoms and CLS measures Dependent variables (recall period of the last three months unless specified): Adjusted for socio-demographics + lifestyle factors + lifestyle factors + high self- efficacy + lifestyles factors + difficulty discussing condom use   aPR[95% CI] p value Any CLS 1.13 [1.02, 1.26] 0.017 1.08 [0.98, 1.20] 0.137 1.11 [1.00, 1.23] 0.048 CLS with two or more partners 1.28 [1.05, 1.56] 0.013 1.18 [0.98, 1.44] 0.087 1.23 [1.01, 1.50] 0.039 CLS with an unknown/HIV positive status partner 1.30 [1.09, 1.55] 0.004 1.19 [1.00, 1.42] 0.050 1.23 [1.03, 1.48] 0.023 Receptive CLS with an unknown status partner 1.58 [1.13, 2.21] 0.008 1.46 [1.04, 2.05] 0.030 1.51 [1.07, 2.13] 0.019 STI diagnosis (past year) 1.31 [1.07, 1.60] 0.009 1.27 [1.04, 1.56] 1.28 [1.05, 1.57] 0.016 PEP use (past year) 1.68 [1.22, 2.31] 0.001 1.61 [1.78, 2.21] 0.003 1.62 [1.16, 2.25] Acknowledgements: We thank all study participants. AURAH Study Group: Ada Miltz, Alison Rodger, Janey Sewell, Andrew Speakman, Andrew Phillips, Lorraine Sherr, Richard Gilson, David Asboe, Nneka Nwokolo, Christopher Scott, Sara Day, Martin Fisher, Amanda Clarke, Jane Anderson, Rebecca O'Connell, Monica Lascar, Vanessa Apea, Rageshri Dhairyawan, Mark Gompels, Paymaneh Farazmand, Sris Allan, Susan Mann, Jyoti Dhar, Alan Tang, Daniel Ivens, Tariq Sadiq, Stephen Taylor, Graham Hart, Simon Collins, Anne Johnson, Alec Miners, Jonathan Elford, and Fiona Lampe. AURAH clinic teams: Sharmin Obeyesekera (Barking), John Saunders (Barts), Gerry Gilleran, Cathy Stretton (Birmingham), Nicky Perry, Elaney Youssef, Celia Richardson, Louise Kerr, Mark Roche, David Stacey, Sarah Kirk (Brighton), Louise Jennings, Caroline Holder, Katie-Anne Baker (Bristol), Matthew Robinson, Emma Street (Calderdale & H’field), Abayomi Shomoye (Coventry), Ali Ogilvy (Dean Street), Sfiso Mguni, Rebecca Clark, Cynthia Sajani, Veronica Espa (Homerton), Ali Ogilvy, Sarah Ladd (John Hunter), Jonathan Syred, Lisa Hamza, Lucy Campbell, Emily Wandolo, Janagan Alagarajah (Kings), Linda Mashonganyika, Sally Batham (Leicester), Rita Trombin, Ana Milinkovic, Clare Oakland (Mortimer Market), Nyasha Makoka (Newham), Ruth Wilson, Elizabeth Green, Sheila O'Connor, Sarah Kempster, Katie Keating-Fedders (Reading), Nicola Tyrrell, Jemima Rogers, Silvia Belmondo, Manjit Sohal (Royal Free), 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), James Hand, Nyasha Makoka (The London), Ali Ogilvy (West London Clinic for Sexual Health), and Nyasha Makoka, Elias Phiri, Zandile Maseko (Whipps Cross). AURAH advisory board: Sir Nick Partridge, Kay Orton, Anthony Nardone, Ann Sullivan, Lorraine Sherr, Graham Hart, Simon Collins, Anne Johnson, Alec Miners and Jonathan Elford.