标题：Sexual Risk Behavior, Sexual Violence, and HIV in Persons With Severe Mental Illness in Uganda: Hospital-Based Cross-Sectional Study and National Comparison Data
摘要：Objectives. We investigated prevalence of past-year sexual risk behavior and sexual violence exposure in persons with severe mental illness (SMI) in Uganda, and compared results to general population estimates. We also investigated whether persons with SMI reporting sexual risk behavior and sexual violence exposure were more likely to be HIV-infected. Methods. We included 602 persons consecutively discharged from Butabika Hospital, Kampala, Uganda, February to April 2010. We asked about past-year number of sexual partners and condom use. We assessed sexual violence with the World Health Organization Violence Against Women Instrument. We performed HIV testing. We used data from 2011 Uganda Demographic and Health Survey for comparison. Results. Women with SMI had more sexual risk behavior and more sexual violence exposure than women in the general population. We found no difference in sexual risk behavior in men. Sexual risk behavior was associated with HIV infection in men, but not women. Sexual violence exposure was not associated with HIV infection in women. Conclusions. Findings suggest that SMI exacerbates Ugandan women’s sexual vulnerability. Public health practitioners, policymakers, and legislators should act to protect health and rights of women with SMI in resource-poor settings. Persons with severe mental illness (SMI; schizophrenia, bipolar affective disorder, other psychoses) have higher morbidity 1 and mortality 2–4 from physical health conditions than do persons in the general population. Difficult living conditions in resource-poor settings 5,6 raise further questions about health in this group. Indeed, studies suggest that persons with SMI may have particularly poor survival in resource-poor settings attributable to deaths from common communicable diseases. 7,8 HIV/AIDS is the communicable disease causing most morbidity and mortality in southern and eastern sub-Saharan Africa. 9 Studies in settings with concentrated HIV epidemics have shown a high burden of HIV in persons with SMI, 10–16 potentially because of overlapping HIV risk behaviors with high-risk groups. 17–19 Results from sub-Saharan African settings with generalized HIV epidemics have been more diverse, although with HIV prevalence estimates generally closer to those in general populations. 20–24 In Uganda, 2 facility-based studies have reported high HIV prevalence in persons with SMI compared with persons in the general population. 25,26 In these studies, women with SMI have had particularly high rates relative to the general population. Associations between SMI and HIV may be bidirectional, 27,28 but the Ugandan studies nevertheless raise the question as to whether persons with SMI, and women with SMI in particular, constitute a high-risk group for HIV in this low-income country with a generalized HIV epidemic. In a recent qualitative study in Uganda we described how SMI can increase sexual risk behaviors and the risk of sexual violence in women. 29 Quantitative studies on sexual risk behaviors in persons with SMI in sub-Saharan Africa are, however, few, 23,25,30–34 with only 3 studies providing comparisons with the general population. 23,30,31 In the only study reporting results separately for men and women (Malawi), women but not men had more sexual risk behaviors than the general population. 23 One previous Ugandan study reported data on this topic, but did not compare rates to those in the general population. 25 Furthermore, we are aware of only 1 study reporting data on sexual violence against persons with SMI in sub-Saharan Africa (Ethiopia). 35 This study suggested that sexual violence against persons with SMI may be common, but results were not stratified by gender, and, furthermore, differentiation was not made between sexual violence by partners and by nonpartners. Therefore, we investigated the 12-month prevalence of sexual risk behavior and sexual violence exposure in persons with SMI discharged from a psychiatric hospital in Uganda, and compared estimates to those in a nationally representative survey. In light of our previous qualitative findings, we stratified all comparisons by gender. Furthermore, we investigated whether persons with SMI reporting more sexual risk behavior and sexual violence exposure were more often HIV-positive.
