The intersection of violence, substance use, depression, and STDs: testing of a syndemic pattern among patients attending an urban STD clinic

Effect of nurse home visits vs. usual care on reducing intimate partner violence in young high-risk pregnant women: a randomized controlled trial

BACKGROUND

Expectant mothers and mothers of young children are especially vulnerable to intimate partner violence (IPV). The nurse-family partnership (NFP) is a home visitation program in the United States effective for the prevention of adverse child health outcomes. Evidence regarding the effect of nurse home visiting on IPV is inconsistent. This study aims to study the effect of VoorZorg, the Dutch NFP, on IPV.

METHODS

A random sample of 460 eligible disadvantaged women <26 years, with no previous live births, was randomized. Women in the control group (C; n=223) received usual care; women in the intervention group (I; n=237) received usual care plus nurse home visits periodically during pregnancy and until the child's second birthday.

RESULTS

At 32 weeks of pregnancy, women in the intervention group self-reported significantly less IPV victimization than women in the control group in: level 2 psychological aggression (C: 56% vs. I: 39%), physical assault level 1 (C: 58% vs. I: 40%) and level 2 (C: 31% vs. I: 20%), and level 1 sexual coercion (C: 16% vs. I: 8%). Furthermore, women in the intervention group reported significantly less IPV perpetration in: level 2 psychological aggression (C: 60% vs. I: 46%), level 1 physical assault (C: 65% vs. I: 52%), and level 1 injury (C: 27% vs. I: 17%). At 24 months after birth, IPV victimization was significantly lower in the intervention group for level 1 physical assault (C: 44% vs. I: 26%), and IPV perpetration was significantly lower for level 1 sexual assault (C: 18% vs. I: 3%). Multilevel analyses showed a significant improvement in IPV victimization and perpetration among women in the intervention group at 24 months after birth.

CONCLUSION

VoorZorg, compared with the usual care, is effective in reducing IPV during pregnancy and in the two years after birth among young high-risk women.

TRIAL REGISTRATION

Dutch Trial Register NTR854 http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=854.

Depression and HIV Risk Taking among Men Who Have Sex with Other Men (MSM) and Who Use the Internet to Find Partners for Unprotected Sex

PURPOSE

This study examines the prevalence of depression in a sample of MSM who are at high risk for HIV. It examines the relationship between depressive symptomatology and involvement in HIV risk behaviors, and the factors associated with greater depressive symptomatology.

METHODS

The data come from a national random sample of 332 MSM who used any of 16 websites to identify men with whom they could engage in unprotected sex. Data were collected via telephone interviews.

RESULTS

Depression was more prevalent in this population (26.7%) than among men in the general population. Depression was not related directly to any of the HIV risk behaviors examined, but it was related to men's attitudes toward condom use, which was the strongest predictor of their involvement in risky behaviors. Five factors were identified as being associated with greater depression: lower educational attainment, greater discrimination based on sexual orientation, greater eroticizing of ejaculatory fluids, experiencing more substance abuse problems, and greater childhood maltreatment.

CONCLUSIONS

Depression is a consequential problem in this population. Although depression does not appear to be related directly to HIV risk practices in this population, its influence cannot be discounted because of its effects on other key predictors of risk involvement.

A case-control study of risk and protective factors for incarceration among urban youth

PURPOSE

Each day in the United States, approximately 100,000 youth are under correctional supervision. The purpose of this study is to examine the early risk and protective factors for incarceration using a high-risk sample of urban youth.

METHODS

Data were obtained from 2,165 (54 who were incarcerated) youth who participated in Project Northland Chicago. Participants were matched exactly on gender, race/ethnicity, and aggressive behavior in sixth grade. Bivariate and multivariate conditional logistic regression analyses were used to examine the risk and protective factors present at sixth grade that increased the odds of incarceration at 12th grade.

RESULTS

The early risk factors for incarceration were age (odds ratio [OR] = 2.51; 95% confidence interval [CI] 1.71-3.69), having been sent to detention (1-3 times: OR = 2.24; 95% CI 1.15-4.37; 4+ times: OR = 3.49; 95% CI 1.40-8.72), and the number of hours spent participating in a sport (OR = 1.11; 95% CI 1.03-1.20). Substance use was not significantly related to incarceration after adjusting for other behavioral and contextual risk factors.

CONCLUSIONS

General problem behaviors (nonaggressive) strongly predict incarceration among at-risk youth. Implications for prevention programs are discussed.

Longitudinal associations between health behaviors and mental health in low-income adults

Although there are established relationships between physical and mental health, few studies have explored the relationship between health behaviors and mental health over time. To explore rates of health-compromising behaviors (HCBs) and the longitudinal relationship between HCBs and depression, anxiety, and stress, five waves of data were collected over 1 year from 482 patients at an urban public health clinic (47 % female, 68 % African-American, M age = 28). Smoking (61 %), binge drinking (52 %), illegal drug use (53 %), unprotected sex with non-primary partners (55 %), and fast food consumption (71 %) were common, while consumption of fruits or vegetables (30 %) and breakfast (17 %) were rare. Cross-lagged models identified within-time associations between HCBs and depression/anxiety and stress. Additionally, depression/anxiety and stress predicted later HCBs, but HCBs did not predict later mental health. Results suggest that targeting mental health may be important to promoting improvements across multiple health behaviors.

A syndemic including cigarette smoking and sexual risk behaviors among a sample of MSM in Shanghai, China

OBJECTIVES

We explored possible correlates of cigarette smoking and their associations with levels of smoking among a sample of Chinese men who have sex with men (MSM). We also explored the syndemic associations of substance use and psychosocial problems on sexual risk behaviors.

METHODS

Cross-sectional data collection from 404 MSM in Shanghai, China.

RESULTS

MSM exhibit a high prevalence of smoking (66.3%). Both light and heavy smoking were associated with alcohol and drug use, depression, intimate partner violence, sexual attitudes, and gay identity (though the associations for light smokers were moderate compared to those for heavy smokers).

CONCLUSIONS

Our findings indicate the presence of a health syndemic among MSM, and suggest that smoking prevention and cessation and other substance abuse interventions should be integrated into efforts preventing sexual risk behaviors among MSM.

Condom use self-efficacy and HIV risk practices among men who use the internet to find male partners for unprotected sex

This research examines the levels of condom use self-efficacy in a population of men who have sex with men who are at great risk for contracting/transmitting HIV. It focuses on the relationship between condom use self-efficacy and risk involvement, and examines the factors associated with greater/lower levels of condom use self-efficacy. The data come from a national sample of men, randomly chosen, who used any of 16 websites specifically to identify other men with whom they could engage in unprotected sex. Data were collected between January 2008 and May 2009 from 332 men, via telephone interviews. Multivariate analyses and structural equation modeling were used to test a conceptual model based on syndemics theory. Overall levels of condom use self-efficacy were fairly high, and self-efficacy was related inversely to involvement in HIV risk practices. Six factors were found to be indicative of levels of condom use self-efficacy: the number of drug problems experienced, sexual role identity as a "bottom," not caring about the HIV serostatus of potential sex partners, experiencing childhood maltreatment, having confidence in HIV-related information provided in other men's online profiles, and level of HIV knowledge. Condom use self-efficacy plays an integral role in HIV risk practices among high-risk men who have sex with men. This is true despite the fact that, overall, condom use self-efficacy levels were fairly high in this population.

Perceived importance of five different health issues for gay and bisexual men: implications for new directions in health education and prevention

This study assessed the perceived importance of five health issues for gay and bisexual men (N = 660) using time-space sampling in gay bars/clubs and bathhouses in New York City: "HIV & STDs," "Drugs & Alcohol," "Body Image," "Mental Health," and "Smoking." This study compared ratings based on demographic differences, recent substance use, recent sexual risk behavior, and whether or not participants owned a smart device (e.g., "smart" phone, iPad, iPod touch). Contrary to research indicating that gay and bisexual men may be experiencing HIV prevention fatigue, this study identified that HIV and STIs were perceived as most important. Drugs and alcohol and mental health were also rated high, suggesting that providers may be well served to include mental health and drugs and alcohol as part of their comprehensive approach to HIV prevention. A majority of participants (72%) owned a smart device. Smart device owners rated health issues similarly to those who did not, suggesting that such devices may be a useful platform to reach gay and bisexual men for health education and prevention.

Understanding barriers to sexual health service access among substance-misusing women on the South East coast of England

OBJECTIVES

Evidence suggests substance-misusing women (SMW) experience disproportionate sexual health morbidity and poor uptake of interventions including contraception and cervical screening, yet there has been little investigation of sexual health service access issues for this population.

METHODS

Twenty women with problem drug use in Hastings in South East England, UK participated in a one-to-one interview with a researcher to explore experiences and beliefs surrounding access to a range of sexual health service interventions. Transcripts were open-coded and themes were elicited and organised concerning barriers to access.

RESULTS

Drug-use lifestyles, trauma and low self-worth framed the lives of SMW and hindered sexual health service access through: depleted practical and emotional resources to enable attendance; high perceived emotional cost of discussing sexual histories, and coping with tests and unfavourable results; and low anticipated value of sexual health interventions due to low perception and minimisation of risk and perceived incompatibility between drug use and sexual well-being.

CONCLUSIONS

A range of practical, social and emotional barriers to sexual health service access exist for this population, presenting a context from within which use of services may come at considerable personal cost to SMW. Interventions addressing anticipated stigma and emotional, hygiene and fiscal concerns are warranted for this population.

Sadness in the SUN: using computerized screening to analyze correlates of depression and adherence in HIV-infected adults in the United States

We used a standardized screening tool to examine frequency of depression and its relation to antiretroviral medication adherence among HIV-infected persons on highly active antiretroviral therapy (HAART) in the Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy (SUN Study). This is a prospective observational cohort of 700 HIV-infected patients enrolled between March 2004 and June 2006 in four U.S. cities, who completed a confidential audio computer-assisted self-interview [ACASI] with behavioral risk and health-related questions at baseline and 6-month follow-up visits, including the nine-question PRIME-MD depression screener and a validated 3-day antiretroviral adherence question. Among 539 eligible participants receiving HAART, 14% had depression at baseline (22% women, 12% men). In multivariable analysis using generalized estimating equations (GEE) to account for repeated measurements through 24 months of follow-up, persons who reported depression on a given ACASI were twice as likely to report nonadherence to antiretrovirals on the same ACASI (Odds ratio [OR] 2.02, 95% CI: 1.15, 3.57] for mild/moderate depression versus none); such persons were also less likely to have HIV viral load<400 copies/mL. Self-administered computerized standardized screening tools can identify at-risk individuals with depression who may benefit from interventions to improve antiretroviral adherence.

Exposure to Different Types of Violence and Subsequent Sexual Risk Behavior among Female STD Clinic Patients: A Latent Class Analysis

OBJECTIVE

Diverse forms of violence, including childhood maltreatment (CM), intimate partner violence (IPV), and exposure to community violence (ECV), have been linked separately with sexual risk behaviors. However, few studies have explored multiple experiences of violence simultaneously in relation to sexual risk-taking, especially in women who are most vulnerable to violent experiences.

METHODS

Participants were 481 women (66% African American, M_age = 27 years) attending a publicly-funded STD clinic who reported on their past and current experiences with violence and their current sexual risk behavior. We identified patterns of experience with violence using latent class analysis (LCA) and investigated which combinations of experiences were associated with the riskiest sexual outcomes.

RESULTS

Four classes of women with different experiences of violence were identified: Low Violence (39%), Predominantly ECV (20%), Predominantly CM (23%), and Multiply Victimized (18%). Women in the Multiply Victimized and Predominantly ECV classes reported the highest levels of sexual risk behavior, including more lifetime sexual partners and a greater likelihood of receiving STD treatment and using substances before sex.

CONCLUSIONS

Women with different patterns of violent experiences differed in their sexual risk behavior. Interventions to reduce sexual risk should address violence against women, focusing on experiences with multiple types of violence and experiences specifically with ECV. Additional research is needed to determine the best ways to address violence in sexual risk reduction interventions.

Risk and Protective Factors for Trajectories of Violent Delinquency Among a Nationally Representative Sample of Early Adolescents

To estimate trajectories of violence using a longitudinal sample of adolescents, considering the effects of multiple domains of influences as differentiators between profiles of violent behavior. A nationally representative sample of 9,421 adolescents ages 15-26. Trajectories were estimated, and multinomial regression procedures were used to evaluate factors predicting membership in high-violence trajectory groups. Mediation analyses were conducted to evaluate the mediated effect of distal influences on violence. Three groups of violence trajectories were identified: (a) nonviolent (73.1%); (b) escalators (14.6%); and (c) desistors (12.3%). Peer alcohol use predicted both escalation and desistance; however, these effects were mediated through individual-level variables. Aside from baseline violence, no other risk factor predicted membership in the "escalator" group. The lack of significance in predicting escalation highlights the need for further study on the etiology of late onset violence. Implications for violence prevention are discussed.

Victimization and Violent Offending: An Assessment of the Victim-Offender Overlap Among Native American Adolescents and Young Adults

The purpose of this article is to evaluate the victim-offender overlap among a nationally representative sample of Native American adolescents and young adults. Data for this study were obtained from 338 Native American youth who participated in the National Longitudinal Study of Adolescent Health (Add Health) Waves I-IV. Group-based trajectory modeling was used to estimate trajectories of violence and victimization separately. Bivariate tests were used to assess the overlap between victimization and violent trajectory groups. Multinomial regression procedures were used to assess the predictors of victimization, offending, and the overlap category of both victimization and offending. Three trajectory groups were found for violence (nonviolent, escalators, and desistors) and victimization (nonvictim, decreasing victimization, and increasing victimization). We found substantial evidence of an overlap between victimization and offending among Native Americans, as 27.5% of the sample reported both victimization and offending. Those in the overlap group had greater number of risk factors present at baseline. These results suggest that the victim-offender overlap is present in Native American adolescents. Explanations and implications are discussed.

Childhood Maltreatment and HIV Risk-Taking among Men Using the Internet Specifically to Find Partners for Unprotected Sex

PURPOSE

Using a Syndemics Theory conceptual model, this study examines the relationship between childhood maltreatment experiences and involvement in HIV risk taking in a sample of adult men who actively seek partners for unprotected sex via the Internet. One of the main advantages to using this theoretical model is that it considers the co-varying influences of factors such as childhood maltreatment, psychological/psychosocial functioning, risk-related preferences, demographic characteristics, substance use/abuse, and attitudes toward risk taking on actual risk practices.

METHODS

The study was based on a national random sample of 332 MSM who use the Internet to seek men with whom they can engage in unprotected sex. Data collection was conducted via telephone interviews between January 2008 and May 2009. Structural equation analysis was undertaken to examine the specific nature of the relationships involved in understanding HIV risk practices.

RESULTS

Childhood maltreatment experiences were not found to be related directly to involvement in HIV risk taking in adulthood. Childhood maltreatment, particularly in the form of emotional neglect, was found to be an important variable in the overall structural equation. Its effect on HIV risk taking was indirect, operating principally by having a negative impact upon self-esteem, which in turn had a negative effect on attitudes toward condom use, which in turn were related strongly and directly to risk taking.

CONCLUSIONS

Childhood maltreatment experiences are relevant to understanding HIV risk practices among MSM in adulthood, but the relationship is not as simple as usually conceptualized. Rather, childhood maltreatment appears to impact risk taking indirectly, through its effects on mental health functioning, which in turn affects risk-related attitudes.

The Mediated Effect of Contextual Risk Factors on Trajectories of Violence: Results from a Nationally Representative, Longitudinal Sample of Hispanic Adolescents

The current study sought to estimate trajectories of violent behavior and evaluate the direct and indirect effects of contextual factors among Hispanics, stratified by gender. Relying on data from 3,719 Hispanic adolescents surveyed as a part of the National Longitudinal Study of Adolescent Health (Add Health), violence trajectories were estimated using group-based trajectory modeling. The results identified three groups of violence trajectories for both males and females (non-violent, desistors, and escalators) and there were considerable gender differences in the direct and indirect effects of risk and protective factors on violent behavior. Study limitations and policy implications are also discussed.

Sexual compulsivity, co-occurring psychosocial health problems, and HIV risk among gay and bisexual men: further evidence of a syndemic

OBJECTIVES

We evaluated whether sexual compulsivity fits into a syndemic framework, in which sexual compulsivity is one of a number of co-occurring psychosocial health problems that increase HIV risk among men who have sex with men (MSM).

METHODS

In 2003 and 2004, we conducted an anonymous cross-sectional survey of MSM in New York City (n = 669) by approaching attendees at gay, lesbian, and bisexual community events. We analyzed data by bivariate and multivariate logistic regression.

RESULTS

We found strong positive interrelationships among syndemic factors including sexual compulsivity, depression, childhood sexual abuse, intimate partner violence, and polydrug use. In bivariate analyses, all syndemic health problems except for childhood sexual abuse were positively related to HIV seropositivity and high-risk sexual behavior. Our multivariate models revealed an array of interrelationships among psychosocial health problems. We found amplified effects of these problems on HIV seropositivity and on the likelihood of engaging in high-risk sexual behavior.

CONCLUSIONS

Our findings support the conclusion that sexual compulsivity is a component of a syndemic framework for HIV risk among MSM. HIV prevention interventions should consider the overlapping and compounding effects of psychosocial problems, including sexual compulsivity.

Mental health and HIV sexual risk behavior among patrons of alcohol serving venues in Cape Town, South Africa

BACKGROUND

Alcohol-serving venues in South Africa provide a location for HIV prevention interventions due to risk factors of patrons in these establishments. Understanding the association between mental health and risk behaviors in these settings may inform interventions that address alcohol use and HIV prevention.

METHODS

Participants (n = 738) were surveyed in 6 alcohol-serving venues in Cape Town to assess post-traumatic stress disorder (PTSD) and depression symptoms, traumatic experiences, sexual behavior, and substance use. Logistic regression models examined whether traumatic experiences predicted PTSD and depression. Generalized linear models examined whether substance use, PTSD, and depressive symptoms predicted unprotected sexual intercourse. Men and women were analyzed separately.

RESULTS

Participants exhibited high rates of traumatic experiences, PTSD, depression, alcohol consumption, and HIV risk behaviors. For men, PTSD was associated with being hit by a sex partner, physical child abuse, sexual child abuse and HIV diagnosis; depression was associated with being hit by a sex partner, forced sex and physical child abuse. For women, both PTSD and depression were associated with being hit by a sex partner, forced sex, and physical child abuse. Unprotected sexual intercourse was associated with age, frequency and quantity of alcohol use, drug use, and PTSD for men and frequency and quantity of alcohol use, depression, and PTSD for women.

CONCLUSION

Mental health in this setting was poor and was associated with sexual risk behavior. Treating mental health and substance-use problems may aid in reducing HIV infection. Sexual assault prevention and treatment after sexual assault may strengthen HIV prevention efforts.

Mediators of the relation between partner violence and sexual risk behavior among women attending a sexually transmitted disease clinic

BACKGROUND

Intimate partner violence (IPV) is associated with a wide range of negative outcomes, including sexual risk behavior. This cross-sectional study explored mediators of the relationship between IPV and risky sexual behavior in 717 women recruited from a sexually transmitted disease (STD) clinic.

METHODS

Participants were recruited from a public STD clinic in upstate New York as part of a randomized controlled trial that was designed to evaluate several sexual risk reduction interventions. They completed an audio computer-assisted self-interview in a private room.

RESULTS

Among these women, 18% reported IPV in the past 3 months and 57% reported lifetime experience of IPV. Recent IPV was associated with greater sexual risk, as measured by more episodes of unprotected sex (overall and with a steady partner). Although IPV was associated with depressive symptoms and drug use before sex, these variables did not mediate the relationship between IPV and sexual risk behavior.

CONCLUSIONS

The results indicate that IPV is common among women who attend an STD clinic and warrants increased attention. Research is needed to better understand the pathways linking IPV and HIV risk in women, to optimize the design of effective interventions.