AIDS PATIENT CARE and STDs ORIGINAL ARTICLE

Volume XX, Number XX, 2017

ª Mary Ann Liebert, Inc.
DOI: 10.1089/apc.2016.0259

Body Image and Risk Behaviors in Youth with HIV

Ronald H. Dallas, PhD,1 Megan M. Loew, MS,2 Megan L. Wilkins, PhD,1,2 Yilun Sun, MS,3
Li Tang, PhD,3 Jerlym S. Porter, PhD,2 and Aditya H. Gaur, MD1

Abstract

Body image concerns are common among people living with HIV. Among adults with HIV, body image
concerns have been shown to be related to risky sexual behaviors; little research has been conducted among
youth living with HIV (YLWH). The current study examined the predictors, including body image, of sexual
risk behaviors among YLWH. Adolescents from a single clinic (n = 143; age range 16–24 years; 69% male;
95% African American) completed a computerized self-report survey to assess demographic, behavioral, and
body image domains. Demographic and clinical data were abstracted from the medical record. Logistic re-
gression analyses assessed associations between risk factors and risky sexual behaviors. Results indicated that
YLWH who reported less favorable body image perceptions ( p = 0.04) and more sexual partners ( p = 0.05) were
less likely to use condoms during their last sexual encounter. YLWH with six or more sexual partners were
more likely to use drugs or alcohol during their last sexual encounter ( p = 0.03). A belief that their HIV
medications changed their body physically ( p = 0.05), history of HIV-related complications ( p = 0.03), an
undetectable viral load at their most recent clinical laboratory draw ( p = 0.01), and having a high school
diploma or equivalent ( p = 0.001) were independently associated with disclosure of participant’s HIV status to a
romantic/sexual partner. Findings suggest that body image perceptions may influence risky sexual behavior in
YLWH. Further study is warranted to understand and intervene upon this relationship to improve individual and
public health outcomes.

Keywords: HIV, body image, risky sexual behaviors, youth, adolescents

Introduction such as depressive symptoms, which among YLWH have

C oncerns about body image are a common occurrence
among adults living with HIV.1 Body image among
adults living with HIV has also been shown to be related
to risky sexual behavior.2,3 Multiple physical, psychosocial,
and cultural factors influence one’s body image. In turn,
body image may impact upon an individual’s engagement in
HIV-related self-care behaviors (e.g., transmission risk re-
duction, and medication adherence). Emerging evidence
among adults living with HIV has highlighted the role body
image disturbance may exert on HIV self-care behaviors that
influence both individual and public health related outcomes;
however, there is sparse evidence among youth living with
HIV (YLWH).2
YLWH are prone to struggle with health and/or poor body
image, as well as engage in sexual transmission risk behav-
iors.4,5 Body dissatisfaction has been shown to contribute to
negative emotions and psychosocial problems in YLWH
been associated with reduced medication adherence and in-
creased risk behaviors.6–8 This is of concern given that youth
accounted for *26% of new HIV infections in the United
States in 2010.9 As a result, research is urgently needed ex-
amining novel pathways that predict HIV transmission risk
among YLWH to inform effective intervention development.
High-risk sexual behaviors among people living with HIV
can have detrimental individual and public health level
consequences.10 Research has shown a relationship between
body image and sexual risk behaviors across multiple age,
ethnic, and sexual preference groups.11 Poor body image may
impact condom self-efficacy, increasing one’s risk of ac-
quiring or transmitting HIV.12 Evidence suggests that more
YLWH engage in risky sexual behaviors compared to adults
with HIV.13 In another study examining risk behaviors
among YLWH, almost half of youth reported engaging in
unprotected sex since learning they had HIV.14 In addition to
adolescent risk factors such as use of social media to connect

Departments of 1Infectious Diseases, 2Psychology, and 3Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee.

1
2 DALLAS ET AL.
with partners, low concern about HIV infection, and infrequent
discussion about HIV status,15 body image may play a role in
increasing risks. Despite the recognized relationship between
body image and high-risk sexual behavior, studies examining
this among YLWH are lacking and urgently needed.
To address this identified gap in the literature, the current
study aimed to examine the predictors, including body image
measures, of sexual risk behaviors among YLWH. It was
hypothesized that negative body image perceptions would be
significantly related to increased HIV sexual transmission
risk behaviors. For the purposes of this study, youth will be
defined as those between the ages of 16 and 24 years old.
Methods
Participants and procedure
This study was a secondary analysis from an existing da-
taset. The dataset used was collected as a cross-sectional
exploratory pilot study of body image in a sample of YLWH.
The purpose of the original study16 was to explore self-
reported body image, health behaviors, clinical, and socio-
demographic factors among YLWH.
Participants were recruited using a census approach
from an adolescent infectious diseases (ID) clinic in the
Mid-southern United States. Inclusion criteria included the
following: youth (aged 16–23 years old inclusive) with
documented diagnosis of HIV infection, awareness of HIV
diagnosis, primary language was English, and ability to pro-
vide informed consent. Youth with significant motor, sen-
sory, or other impairments that precluded participation in
the study as determined by the clinic psychologist were ex-
cluded. Participants completed an audio computer-assisted
self-interview (ACASI)17 in a private area of the clinic and
received $10 compensation for their time and effort. The
electronic survey was reviewed by the ID clinic’s youth
community advisory board, and recommendations were in-
corporated into the final script. Relevant demographic and
clinical data were also abstracted from the youth’s medical
record. This study was approved by the clinic site’s institu-
tional review board.
Measures
Demographics questionnaire. Participants were asked
several demographic questions, including gender, education
status, sexual identity, sexual history [e.g., men who have sex
with men (MSM)], and race. Social/environmental questions
were also collected and included with whom the participant
lives and whether/not they receive public assistance (e.g.,
public health insurance, food stamps, or other public financial
support).
Multi-dimensional Body-Self Relations Questionnaire.
The Multi-dimensional Body-Self Relations Questionnaire
(MBSRQ) is a well-validated self-report inventory for the
assessment of body image.18 Internal consistency of the
subscales on the MBSRQ ranges from a = 0.70–0.91 for male
respondents and a = 0.73–0.90 for female respondents. Test–
retest reliability estimates ranged from 0.71 to 0.89 for male
respondents and 0.74 to 0.94 across subscales at 1-month
follow-up for female respondents. The MBSRQ is intended
for use with individuals 15 years or older. This study used
the MBSRQ-Appearance Scales (AS).18 The MBSRQ-AS is a
shortened 34-item measure from the MBSRQ that consists of
five subscales: Appearance Evaluation, Appearance Orienta-
tion, Overweight Preoccupation, Self-Classified Weight, and
the Body Areas Satisfaction Scale (BASS). To estimate overall
body image from this measure, a combination score from the
Appearance Evaluation and BASS was derived.18
Figure Rating Scale. The Figure Rating Scale used for
this study is modeled after Stunkard’s19 widely used nine-
figure scale. The current version is a culturally relevant
measure of body size satisfaction; the figures have hair and
facial features resembling people with multi-ethnic back-
grounds. It consists of a series of nine schematic figures of
varying size. Findings indicate good test–retest reliability and
moderate correlations with other measures of body dissatis-
faction, eating disturbance, and overall self-esteem.20 Parti-
cipants were asked to identify which image they find most
similar to their current body type, as well as their ideal or
preferred body type.
Youth Risk Behavior Survey. The Youth Risk Behavior
Survey monitors priority health-risk behaviors and the
prevalence of obesity and asthma among youth in the United
States.21 The Youth Risk Behavior Surveillance System
(YRBSS)21 includes a national school-based survey con-
ducted by the Centers for Disease Control and Prevention
(CDC) and state, territorial, tribal, and district surveys con-
ducted by education and health agencies/governments. The
YRBSS monitors six categories of priority health-risk be-
haviors among youth and young adults, including behaviors
that contribute to unintentional injuries and violence; tobacco
use; alcohol and other drug use; sexual behaviors related to
unintentional pregnancy and sexually transmitted infections,
including HIV; unhealthy dietary behaviors; and physical
inactivity.21 For the purposes of this study, select questions
pertaining to sexual behaviors and drug use were included.
Center for Epidemiologic Studies Depression Scale–Short
Form. The Center for Epidemiologic Studies Depression
Scale–Short Form (CES-D-10) is the abbreviated version of
one of the most commonly used self-report depression scales
designed for use in clinical and research settings.22 The
CES-D-10 has been found to perform, as well as the full item
questionnaire.23 Cronbach’s alpha for the CES-D-10 scale
reliability has consistently exceeded 0.8, and item-to-total
correlations have been low (<0.5).22 High internal consis-
tency also has been reported.22,23 The range of scores is 0–30
with higher scores representing a more depressed mood. With
all 10 items, the CES-D-10 can be regarded as a measure
of affect (i.e., the presence of negative affect and, to a lesser
extent, the absence of positive affect). A cutoff score of 10
has been recommended for the categorization of depres-
sion22; therefore, those with a score of 10 or higher were
categorized as having elevated depressive symptoms for the
purpose of these analyses.
In addition to the measures above, participants currently
taking antiretroviral (ARV) medications were asked if they
believed their ARVs were causing changes to their body.
Female participants who were currently prescribed hormonal
contraceptives were asked if they believed their birth control
medications caused weight loss or weight gain and if they
BODY IMAGE AND RISK BEHAVIORS IN YOUTH WITH HIV 3

ever stopped taking their birth control medication due to Table 2. Factors Associated with Using
concerns that it was causing body weight changes. a Condom During Last Sexual Encounter
Univariate Multivariate
Medical record/chart abstraction. Demographic and health analyses analyses
status variables, such as disease and treatment status, laboratory
values, and vital signs, were abstracted from the participant’s Odds ratio Odds ratio
medical record by study staff. Specific values collected for these (95% CI) p (95% CI) p
analyses included: participant’s most recent height, weight, and
No of sexual partners
body mass index (BMI). Calculated BMI scores also were cat- One to five people Ref
egorized based on the CDC standard weight status categories Six or more people 0.39 0.03 0.39 0.04
(underweight, normal, overweight, and obese) for BMI.24 (0.16–0.93) (0.16–0.96)
Appearance evaluation 2.02 0.04 1.93 0.05
Analyses and body areas (1.05–3.90) (0.99–3.77)
satisfaction
Descriptive statistics was used to describe and characterize combination score
the sample. Associations with risky sexual behaviors were as-
sessed using univariate and multiple logistic regression models. CI, confidence Interval.
Risk factors with a p-value below 0.1 in univariate logistic
regressions were included in multiple logistic regressions, and a American. Approximately 83% of the sample had acquired
backward selection was performed until all remaining factors HIV through behavioral contact and 82.8% of males in the
were significant at the 0.1 level. Data analyses were conducted study identified as MSM. The mean BMI for the total sample
using SAS version 9.3 and IBM SPSS version 23. was 25.3 (SD = 6.13), CD4 count was 653.4 (SD = 312.1), and
viral load was 12,782.1 copies/mL (SD = 32,538.5). See
Results Table 1 for further sample characteristics.
Using a condom at last sexual encounter was associated
A total of 148 potential participants were approached for with the combined appearance evaluation and body areas
study participation. Of these 148, 5 declined to participate satisfaction scale (AE BASS) score [odds ratio (OR) 1.93;
due to lack of time or being uninterested in the study. Parti- 95% confidence interval (CI) 0.99–3.77; p = 0.05] and num-
cipants were 143 HIV-infected YLWH with an average age ber of sexual partners (OR 0.39; 95% CI 0.16–0.96; p = 0.04),
of 20.7 years (SD = 1.98; range = 16.02–23.98 years). The with participants having higher AE BASS combination
majority was male (69.2%), and 95.1% were black/African scores and fewer number of sexual partners being more likely
to use a condom during their last sexual encounter (Table 2).
Compared to participants with one to five total sexual part-
Table 1. Sample Characteristics ners, participants with six or more sexual partners were more
N = 143 likely to use drugs or alcohol during their last sexual en-
counter (OR 2.49; 95% CI 1.11–5.57; p = 0.03; Table 3).
Age, median (range) 20.98 (16.02–23.98) Participants who received their high school diploma or
Gender, n (%) General Education Development (GED) were more likely to
Male 99 (69.2) have disclosed their diagnosis to a romantic or sexual partner
Female 44 (30.8) (OR 8.33; 95% CI 2.30–30.23; p = 0.001). Those who en-
Race/Ethnicity, n (%) dorsed believing that their ARVs had changed their body
Black 136 (95.1) were more likely to have disclosed their diagnosis to a ro-
White 6 (4.2) mantic or sexual partner (OR 2.98; 95% CI 1.0–8.91;
Other 1 (0.7)
Mode of HIV acquisition, n (%) Table 3. Factors Associated with Using Drugs
Perinatal 24 (16.8) or Alcohol at Last Sexual Encounter
Behavioral 119 (83.2)
MSM, n (%) Univariate Multivariate
Not MSM 17 (17.2) analyses analyses
MSM 82 (82.8) Odds ratio Odds ratio
Prescribed ARVs, n (%) (95% CI) p (95% CI) p
Yes 108 (75.5)
No 35 (24.5) No of sexual partners
Body mass index, mean (SD) 25.3 (6.13) One to five people Ref
CD4 absolute, mean (SD) 653.4 (312.1) Six or more people 2.49 0.03 2.49 0.03
CD4 percentage, mean (SD) 30.8 (10.7) (1.11–5.57) (1.11–5.57)
HIV viral load (copies/mL), 12,782.1 (32,538.5) Depressive symptoms
mean (SD) No Ref
Average weight (kg), 69.4 (44.7–159.1) Yes 1.94 0.09
median (range) (0.89–4.24)
ARVs, antiretrovirals; MSM, men who have sex with men; SD, Backward selection analysis eliminated depressive symptoms at
standard deviation. p < 0.10 level from the final model shown.
4 DALLAS ET AL.

Table 4. Factors Associated with Disclosing HIV Diagnosis to Romantic and/or Sexual Partners
Univariate analyses Multivariate analyses
Odds ratio (95% CI) p Odds ratio (95% CI) p
Belief that ARVs have caused physical changes to body
No Ref
Yes 2.22 (0.88–5.61) 0.09 2.98 (1.00–8.91) 0.05
Received high school diploma or GED
No Ref
Yes 3.48 (1.39–8.71) 0.01 8.33 (2.30–30.23) 0.001
Undetectable viral load
No (‡ 400 copies/mL) Ref
Yes (< 400 copies/mL) 2.18 (1.02–4.66) 0.05 4.53 (1.40–14.69) 0.01
History of HIV related diagnosis
No Ref
Yes 2.40 (0.90–6.46) 0.08 6.18 (1.24–30.94) 0.03
No of sexual partners
One to five people Ref
Six or more people 2.83 (1.23–6.50) 0.01
Backward selection analysis eliminated number of sexual partners at p < 0.10 level from the final model shown.
GED, General Education Development.

p = 0.05). Participants with a history of a HIV related com-
plication (OR 6.18; 95% CI 1.24–30.94; p = 0.03) and an
undetectable viral load (OR 4.53; 95% CI 1.40–14.69;
p = 0.02) also were more likely to have disclosed their HIV
diagnosis to a romantic and/or sexual partner (Table 4).
Participants who reported disclosing their diagnosis to their
most recent sexual partner (OR 3.37; 95% CI 1.36–8.35;
p = 0.009) were not overweight or obese based on the BMI CDC
range ( p = 0.007) and reported using drugs or alcohol at their
most recent sexual encounter (OR 2.65; 95% CI 1.04–6.75;
p = 0.04), but were significantly associated with having six or
more sexual partners in the final adjusted multivariate model
(Table 5). No factors were significantly associated with those who
reported engaging in sexual intercourse before the age of 17 years.
Discussion
Consistent with previous literature,2 these findings suggest
that body image perceptions among YLWH may influence
HIV transmission risk behaviors. Specifically, youth with
positive feelings about their overall appearance and con-
tentment with most areas of their body were more likely to

Table 5. Factors Associated with Six or More Sexual Partners

Univariate analyses Multivariate analyses
Odds ratio (95% CI) p Odds ratio (95% CI) p
Body mass index (CDC Categorization)
Normal/underweight Ref
Overweight 0.27 (0.10–0.73) 0.01 0.18 (0.06–0.55) 0.003
Obese 0.51 (0.20–1.33) 0.17 0.40 (0.14–1.14) 0.09
Disclosed HIV status to romantic and/or sexual partner
No Ref
Yes 2.83 (1.23–6.50) 0.01 3.37 (1.36–8.35) 0.009
Used drugs or alcohol at most recent sexual encounter
No Ref
Yes 2.49 (1.11–5.57) 0.03 2.65 (1.04–6.75) 0.04
Used condoms at most recent sexual encounter
No Ref
Yes 0.39 (0.16–0.93) 0.03
Gender
Male Ref
Female 0.42 (0.19–0.97) 0.04
Belief that ARV medications caused physical changes in body
No Ref 0.058
Yes 2.29 (0.97–5.39)
Backward selection analysis eliminated condom use, gender, and ARV body changes at p < 0.10 level from the final model shown.
BODY IMAGE AND RISK BEHAVIORS IN YOUTH WITH HIV
report using a condom at their last sexual encounter. Previous
literature in this area has primarily focused on adults with HIV
limiting the examination of the relationship between body
image and risk behaviors among YLWH. Thus, the current
study adds to the literature by providing data for clinicians and
researchers about the potential relatedness of body image
perceptions and health behaviors in this population.
Results from a recent meta-analysis found an association
between high scores of body dissatisfaction and low scores of
condom use self-efficacy.12 While the present study did not
examine condom use self-efficacy, our results did find an
association between using a condom with the most recent
sexual partner and increased satisfaction with overall and
specific areas of the body. It is possible that youth with in-
creased body satisfaction are more likely to engage in be-
haviors to protect their body, such as using a condom.25 As
such, it will be important to further investigate the relation-
ship between condom use and body image perception, as a
potential component to designing effective interventions to
prevent secondary transmission of HIV.
It is interesting to note that participants who indicated that
they believed their ARV medications had physically changed
their body were more likely to disclose their HIV diagnosis to
a romantic or sexual partner. This result is in contrast to
previous findings among adults that did not find a relationship
between diagnosis disclosure and perceived body changes as
a result of ARV therapy.26 One potential reason for our
findings could be that perceived physical changes in con-
junction with other HIV clinical progression (e.g., low CD4
count) indicators have been found to predict HIV status
disclosure.27 Still, the specific relationship between disclo-
sure of HIV status to one’s partner and the belief that ARV
medication has caused physical changes in the body is un-
clear. Future research is needed to further investigate and
clarify this relationship.
Limitations of this study include its cross-sectional design,
which constricted our ability to make causal inferences.
However, these results provide data for the development of
future evaluations to further explore body image among
YLWH. In addition, results from this study have the potential
to inform clinical practice by highlighting possible avenues
of discussion and intervention with patients when address-
ing health behaviors related to HIV transmission risk re-
duction. This study was also conducted at a single clinic site,
which may limit its ability to generalize to other geographic
regions of the United States. In addition, the demographic
composition of our sample also limits the generalizability
of the findings. Future research is needed to longitudinally
explore patterns of body image perception among a di-
verse sample of YLWH in relation to health behavior in a
broader sample.
The results from the present study have the potential to
inform clinical practice and warrant further study. By ex-
ploring the relationship between body image perception and
HIV transmission risk behaviors, results from this study
highlight the importance of addressing psychosocial factors
such as body image with the intent of reducing risky sexual
behaviors among YLWH. Expanding traditional behavioral
risk reduction interventions to include aspects such as body
image, and using novel techniques such as providing edu-
cation and feedback about health status markers using mobile
apps, may strengthen their effectiveness at promoting sexual
5
health.28 Given the well-documented relationship between
body image and health behavior among adults infected with
HIV and the high rate of new adolescent HIV infections in the
United States, further exploration among YLWH is needed.
Further studies are also needed to evaluate body image and
HIV related health behaviors in a larger representative sam-
ple, for the development of multi-behavior integrated inter-
ventions. In addition, results from this study highlight the
importance of assessing and intervening on body image
perceptions as opposed to body size or BMI focused inter-
ventions as a potential mechanism to impact HIV self-care
behaviors. To our knowledge there are no known interven-
tions that address body image perceptions among YLWH;
thus, further exploration is warranted and urgently needed.
Acknowledgments
The authors acknowledge the contribution of clinical re-
search assistant, Melissa Shenep, and psychology graduate
assistant Courtney Peasant, during the data collection phase of
this project. The authors also thank Kirk Knapp for his assis-
tance with data abstraction from electronic patient records.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Ronald H. Dallas, PhD
Department of Infectious Diseases
St. Jude Children’s Research Hospital
262 Danny Thomas Place
Memphis, TN 38105
E-mail: ronald.dallas@stjude.org