A daily process investigation of alcohol-involved sexual risk behavior among economically disadvantaged problem drinkers living with HIV/AIDS

Most recent, modal, or median heroin purchase: Does it matter when estimating market size?

BACKGROUND

Assessing the size of illicit drug markets is an important activity of many government agencies; however, the expenditure-based method for estimating market size relies on the relatively untested assumption that the cash value of the most recent purchase is representative of the average purchase amount. Using panel data, we test the representativeness of the most recent, modal and median purchase compared to the average purchase amount.

METHODS

Data were drawn from a prior study that collected daily transaction-level purchase data from a sample of 120 people who were using heroin regularly. The same study participants completed two distinct two-week waves of data collection, separated by six months. T-tests and bootstrapping were used to detect differences within each wave between the average cash value of participant heroin purchases and the cash value of their most recent, modal and median heroin purchases.

RESULTS

In both waves, we found (a) no evidence that the expected value of the most recent purchase differs from the expected value of the average purchase, and (b) the expected values of the modal and median purchases are smaller than the expected value of the average purchase. These results imply that estimates of total market size based on the modal or median purchase will suffer from a significant downward bias, but that estimates based on the most recent purchase will be unbiased.

CONCLUSIONS

We provide evidence in support of using the most recent (but not the modal or the median) purchase to estimate market size for heroin.

Substance Use, HIV Serostatus Disclosure, and Sexual Risk Behavior in People Living with HIV: An Event-Level Analysis

People living with HIV (PLWH) face difficult decisions about disclosing their HIV status to new sexual partners. Alcohol and other drug use could impact these decision-making processes and subsequent sexual risk behavior. We sought to examine the event-level relationships between substance use, HIV disclosure, and condom use in PLWH and their first-time HIV-negative or unknown status sexual partners. Adult PLWH were recruited from care settings in a southeastern U.S. city. Participants reported their sexual behavior for 28 consecutive days via text message prompts. We employed multilevel covariation in a causal system to examine the event-level relations between substance use and condom use. We proposed that this relationship would be mediated by HIV disclosure and moderated by viral suppression status. A total of 243 participants (83% male, 93% Black) reported 509 sexual events with first-time HIV-negative/unknown status sexual partners. Substance use at the time of sex was negatively associated with disclosure in PLWH with suppressed viral load (OR 0.29, β = - 1.22, 95% CI [- 2.42, - 0.03], p = .045), but differentially associated with condom use in PLWH with detectable versus undetectable viral load. In PLWH with viral suppression, participants who always disclosed versus who never disclosed their HIV status were more likely to use condoms (β = 1.84, 95% CI [0.35, 3.53], p = .017), but inconsistent disclosers were less likely to use a condom after disclosing (OR 0.22, 95% CI [0.07, 0.68], p = .008). Event-level analysis offers a more nuanced understanding of the proximal (substance use, HIV disclosure) and person-level (substance use, viral load) determinants of HIV transmission risk behavior in PLWH.

Health benefits of positive reappraisal coping among people living with HIV/AIDS: A systematic review

People living with HIV/AIDS (PLWHA) often face significant stress, ranging from perceiving identity changes to encountering barriers to daily health behavior engagement. To manage these experiences, many people use positive reappraisal coping (including benefit finding and perceiving growth). Effective coping is highly important for PLWHA; stress reduction has salutary effects on multiple indicators of health. The present systematic review, conducted in PubMed, PsycINFO, and CINAHL, synthesises findings from 33 studies of PLWHA, addressing effects of positive reappraisal on health-related outcomes for adults living with HIV as a chronic illness. Studies were evaluated based on methodological considerations, measurement of key variables, and implications for specific aspects of health. Results suggest that positive reappraisal is often beneficial when dealing with the implications of a potentially traumatic HIV diagnosis on one's identity, although effects may be contextually bound. Implications of these findings are reviewed, emphasizing the importance of positive reappraisal for enhancing health promotion and self-management of HIV. Although the present review is limited by inclusion of multiple disparate outcomes and exclusion of non-English-language articles, these findings inform a comprehensive model of direct and indirect effects of positive reappraisal on emotional, functional, physiological, and behavioural aspects of health useful for guiding future research.

Is Alcohol Use Associated With Increased Risk of Developing Adverse Health Outcomes Among Adults Living With Human Immunodeficiency Virus: A Systematic Review

BACKGROUND

Alcohol use is associated with many HIV-related behaviors that are associated with increased risk of reinfection, transmission, and poorer health outcomes in people living with HIV (PLHIV). The population of middle-aged and older PLHIV is growing because of increased life longevity and aging trend.

METHODS

A systematic review across three databases was conducted to evaluate existing studies that examined the association between alcohol use and medication adherence, high-risk sex behaviors, HIV progression, depression, resource utilization, and survival among studies of PLHIV with an average age of 40 years and above.

RESULTS

Among the 47 included studies, most found a positive association between alcohol use and depression, risky sex behaviors, medication nonadherence, and healthcare resource utilization among PLHIV. The association between alcohol use and response to treatment was variable. The association between alcohol use and survival warrants further study because of lack of existing studies.

CONCLUSIONS

The results of this review support that alcohol use negatively impacts middle-aged and older PLHIV in many aspects; however, there is lack of studies exclusively targeting older PLHIV, and more relevant studies in the future are needed.

Food Insecurity, Substance Use, and Sexual Transmission Risk Behavior Among People Living with HIV: A Daily Level Analysis

People living with HIV in poverty have limited tangible and mental resources coupled with competing demands for these resources. Competing demands require individuals to make choices that may be beneficial to them in the short term but not in the long term. Past research has shown that food insecurity is related to sexual risk behaviors among people living with HIV. Individuals who are food insecure may sell sex in order to obtain food or lack of food may lead to a depletion of mental resources to negotiate safe sex. Substance use may also create additional constraints on these already limited resources. The current study tested the relation between food insecurity and day-level sexual risk behavior and the possible mediating role that alcohol/substance use may play. Men and women living with HIV were enrolled in a 28-day prospective study between October 2012 and April 2014 in which they completed daily text message surveys regarding their sex behaviors and substance/alcohol use in the context of sex. A total of 796 participants reported sex on 3894 days. On days in which sex occurred, baseline food insecurity was negatively associated with daily condom use. There was also a significant effect of substance use in the context of sex on the rates of change in condom use over time, and this interaction between substance use and time was a partial mediator of the relation between food insecurity and condom use. Gender did not moderate this mediation. Situation-specific alcohol and drug use should be integrated into interventions that target food insecurity and HIV prevention.

Alcohol Use and Unprotected Sex Among HIV-Infected Ugandan Adults: Findings from an Event-Level Study

While alcohol is a known risk factor for HIV infection in sub-Saharan Africa (SSA), studies designed to investigate the temporal relationship between alcohol use and unprotected sex are lacking. The purpose of this study was to determine whether alcohol used at the time of a sexual event is associated with unprotected sex at that same event. Data for this study were collected as part of two longitudinal studies of HIV-infected Ugandan adults. A structured questionnaire was administered at regularly scheduled cohort study visits in order to assess the circumstances (e.g., alcohol use, partner type) of the most recent sexual event (MRSE). Generalized estimating equation logistic regression models were used to examine the association between alcohol use (by the participant, the sexual partner, or both the participant and the partner) and the odds of unprotected sex at the sexual event while controlling for participant gender, age, months since HIV diagnosis, unhealthy alcohol use in the prior 3 months, partner type, and HIV status of partner. A total of 627 sexually active participants (57% women) reported 1817 sexual events. Of these events, 19% involved alcohol use and 53% were unprotected. Alcohol use by one's sexual partner (aOR 1.70; 95% CI 1.14, 2.54) or by both partners (aOR 1.78; 95% CI 1.07, 2.98) during the MRSE significantly increased the odds of unprotected sex at that same event. These results add to the growing event-level literature in SSA and support a temporal association between alcohol used prior to a sexual event and subsequent unprotected sex.

What makes the pregnant women revisit public hospitals for research? Participant engagement and retention trial in a public hospital (PERTH): an RCT protocol

BACKGROUND

Cohort studies have public health importance as they effectively provide evidence on determinants of health from a life course perspective. Researchers often confront the poor follow-up rates as a major challenge in the successful conduct of cohort studies. We are currently recruiting in a birth cohort study, titled as "Maternal Antecedents of Adiposity and Studying the Transgenerational role of Hyperglycemia and Insulin" (MAASTHI) in a public hospital; with the aim of assessing maternal glycemic levels on the risk of adverse fetal outcomes. Nested within the ongoing cohort, the proposed trial aims to evaluate the effectiveness of two interventions in improving the follow-up in the cohort study in a public hospital.

METHODS

A randomized trial of 795 pregnant women, with 265 women each in three arms observed through pregnancy, until their baby is 14 weeks old. The comparator group receives a standard leaflet, with details on the importance of glucose testing and regular follow up in pregnancy. Intervention arm-1 will receive the standard leaflet plus individualized messages, through an Interactive Voice Response (IVR) system; a type of computer-linked telephone intervention system to remind the participants about the lab test and follow-up dates. Intervention arm- 2 will have the opportunity to attend Mother and Baby Affairs (MBA) workshops, which will provide information on Gestational Diabetes Mellitus (GDM) screening and management to pregnant women and personalized counselling services. The outcome of interest is the difference in the proportion of participants completing follow-up at different points in time, among three arms.

DISCUSSION

Between the two interventions (IVR and MBA), the study results would uncover the contextually specific, timely intervention, which can increase the proportion of pregnant women followed up in public hospitals. If effective, this study will provide information on an effective intervention, useful in ensuring the success of longitudinal follow-up in the public hospitals.

TRIAL REGISTRATION

NCT03088501 , Date Registered: 16/03/2017.

Sexual Behavior and Heavy Episodic Drinking Across the Transition to Adulthood: Differences by College Attendance

Despite a growing literature on college students' sexual behaviors, little is known about how sexual behaviors, and their associations with alcohol, differ for college and noncollege attenders, and whether these patterns represent changes during college or an extension of pre-college behaviors. This paper applied time-varying effect models to data from the National Longitudinal Study of Adolescent to Adult Health to examine (1) prevalence of four sexual behaviors from ages 14 to 24 and (2) how their association with frequent heavy episodic drinking varied across these ages for college and noncollege attenders. Nonattenders have higher prevalence of all sexual behaviors than college attenders across most ages; however, the association between heavy episodic drinking and sexual behaviors is stronger for college attenders during ages 18-20.

Considering high alcohol and violence neighborhood context using daily diaries and GPS: A pilot study among people living with HIV

Our understanding of how community-level context impacts care of persons living with HIV (PLWH), including antiretroviral therapy (ART) adherence and retention in care, is limited. The objective of this study was to characterize the activity spaces of PLWH from an urban area in Southeastern U.S., where the epidemic is among the nation's highest, and to examine how such activity spaces are associated with daily mood and health behaviors. In this small, pilot study, 11 participants were tracked with a global positioning system (GPS)-enabled application on their smartphones for 2 weeks. Activity spaces were created by connecting GPS points sequentially and adding buffers. Contextual exposure data (e.g., alcohol outlets) were connected to activity spaces. Participants also completed daily diary entry through texts 3 times per day regarding outcomes of substance use behaviors, mood, and medication adherence. This yielded a total of 18,007 GPS polyline records that we aggregated into 258 person-days that captured discrete occasions of exposure to contextual factors and subjects' behaviors and moods. On average, the participants spent 19% of their time awake during the 2-week periods in their residential census tract. Exposure to social and built environment factors such as alcohol outlets was greater when participants were outside versus inside their residential census tract. Exposures on daily routes were also significantly associated with ART adherence, alcohol consumption, and mood. Findings suggest substantial differences between activity spaces and residential contexts. Activity spaces are relevant for PLWH and may impact HIV care and behavioral outcomes such as ART adherence and substance use.

Depressive Symptoms, Disclosure, HIV-Related Stigma, and Coping Following HIV Testing Among Outpatients in Uganda: A Daily Process Analysis

As efforts to end the HIV epidemic accelerate there is emphasis on reaching those living with undiagnosed HIV infection. Newly diagnosed individuals face a number of psychosocial challenges, yet we know little about depressive symptoms in the weeks immediately following diagnosis and how disclosure, coping, and other factors may affect short and longer-term depressive symptoms. Purposively sampled Ugandan outpatients completed structured interviews immediately prior to testing for HIV, daily for 28 days after receiving their test results, and at 3 and 6 months post-test. The sample included a total of 244 participants: 20 who tested HIV positive at baseline and who provided 342 daily data points, and 224 who tested HIV negative at baseline and who provided 4388 daily data points. We used linear mixed effects modeling to examine changes in depressive symptom scores over the 28 day daily interview period and predictors of depressive symptom scores and changes over time. Results from the mixed modeling revealed that while those diagnosed with HIV showed initially high depressive symptoms following diagnosis, their symptoms decreased significantly and on average fell below the cutoff for possible depression approximately 15 days after diagnosis. Among those who tested HIV-negative, on average their depressive symptoms were below the cutoff for possible depression and did not change over time. Among those diagnosed with HIV, disclosure, especially to a partner, on a particular day was associated with higher depressive symptoms that day. However, those who disclosed to their partner during the 28 days after diagnosis had significantly lower depression scores by the end of the 28 days as well as lower depression scores 3 and 6 months after diagnosis than did those who did not disclose to their partner during the 28 days after diagnosis. Scoring higher on HIV-related stigma on a particular day was associated with higher depressive symptoms that day and engaging in positive coping on a particular day was associated with lower depressive symptoms that day. Positive coping also accelerated the decrease in depressive symptoms over time. These data underscore the importance of timely disclosure to partners and suggest that regular depression screening after diagnosis and provision of mental health services could improve HIV care engagement and treatment outcomes.

The Daily Relationship Between Aspects of Food Insecurity and Medication Adherence Among People Living with HIV with Recent Experiences of Hunger

BACKGROUND

Limited access to resources can significantly impact health behaviors. Previous research on food insecurity and HIV has focused on establishing the relationship between lacking access to nutritious food and antiretroviral (ARV) medication non-adherence in a variety of social contexts.

PURPOSE

This study aims to determine if several aspects of food insecurity co-occur with missed doses of medication on a daily basis among a sample of people living with HIV who have recently experienced hunger.

METHODS

The current study utilized a prospective, observational design to test the daily relationship between food insecurity and medication non-adherence. Participants were followed for 45 days and completed daily assessments of food insecurity and alcohol use via interactive text message surveys and electronic medication adherence monitoring using the Wisepill.

RESULTS

Fifty-nine men and women living with HIV contributed a total of 2,655 days of data. Results showed that severe food insecurity (i.e., hunger), but not less severe food insecurity (i.e., worrying about having food), significantly predicted missed doses of medication on a daily level. Daily alcohol use moderated this relationship in an unexpected way; when individuals were hungry and drank alcohol on a given day, they were less likely to miss a dose of medication.

CONCLUSIONS

Among people living with HIV with recent experiences of hunger, this study demonstrates that there is a daily relationship between hunger and non-adherence to antiretroviral therapy. Future research is needed to test interventions designed to directly address the daily relationship between food insecurity and medication non-adherence.

Prospective State and Trait Predictors of Daily Medication Adherence Behavior in HIV

BACKGROUND

Many persons living with HIV (PLWH) are nonadherent to medication. Trait level measures that ask about predictors of adherence in the abstract may not adequately capture state level daily variability that more directly impacts adherence.

OBJECTIVES

This preliminary study was designed to test six predictors of electronically monitored adherence at both the state and trait levels and to compare their relative effects.

METHODS

Using a smartphone, 87 PLWH completed randomly cued daily surveys on thoughts, mood, stress, coping, social support, and treatment motivation. All participants also completed baseline surveys on each construct. These state and trait variables were tested as prospective predictors of next-day adherence in multilevel models, and their relative importance was quantified. The analysis sample consisted of 53 PLWH who stored their most frequent antiretroviral medication in a bottle that time-stamped openings to measure adherence.

RESULTS

Higher state level motivation, OR = 1.55, 95% CI [1.07, 2.24], and negative mood, OR = 1.33, 95% CI [1.07, 1.63], predicted greater adherence the following day. Importantly, these effects were only found at the state level. Trait level control beliefs predicted greater adherence, OR = 1.65, 95% CI [1.17, 2.35], but contrary to prediction, validated trait level measures of mood, stress, coping, social support, and motivation did not.

DISCUSSION

Trait and state level measures predicted adherence, but there were differences between them. Motivation for treatment and negative mood predicted adherence when measured the preceding day, but not as aggregate measures. At the trait level, only control beliefs predicted adherence. Researchers should consider state level variations in mood and motivation as possible explanations for nonadherence. Interventions could be developed to target state level variables.

The role of alcohol use in antiretroviral adherence among individuals living with HIV in South Africa: Event-level findings from a daily diary study

OBJECTIVE

Using daily diary methods, we aimed to test the hypothesis that at the event-level consuming alcohol increases the likelihood that antiretrovirals (ARV) will be missed on a particular day.

METHODS

This prospective cohort study of 74 (52 female, 22 male) people living with HIV (PLHIV) in South Africa collected event-level data on ARV adherence and alcohol consumption using structured daily phone interviews over a period of 42days generating 2718 data points. We used generalized estimating equations (GEE) analyses to assess univariate and multivariate associations between alcohol and adherence, controlling for sociodemographics and testing for effect modification.

RESULTS

Controlling for sociodemographics, each alcohol measure was a statistically significant predictor of non-adherence on a particular day; any drinking compared to no drinking (daytime: AOR=3.18, 95% CI=2.25-4.49; evening: AOR=3.43, 95% CI=2.12-5.53), consuming more alcohol than one normally consumes (daytime: AOR=1.06, 95% CI=1.02-1.11; evening: AOR=1.10, 95% CI=1.05-1.15), and drinking at low to moderate risk level (daytime: 4.29, 95% CI=2.81-6.56; evening: AOR=4.24, 95% CI=2.38-7.54) and high to very high risk levels (daytime: AOR=2.31, 95% CI=1.56-3.42; evening: AOR=3.08, 95% CI=1.91-4.98) were all significantly related to missing ARVs in the daytime and evening.

CONCLUSIONS

These data provide support for an event-level relationship between alcohol and non-adherence. Interventions that mitigate alcohol use among people on ARVs or provide strategies to maintain optimal adherence among those who drink are needed.

The Feasibility and Acceptability of Using Technology-Based Daily Diaries with HIV-Infected Young Men Who have Sex with Men: A Comparison of Internet and Voice Modalities

This study delivered a daily diary to 67 HIV-infected men who have sex with men (MSM) between 16 and 24 years old for 66 days to measure HIV-risk behaviors and other psychosocial variables via two diary modalities: internet (accessible via any web-enabled device) and voice (accessible via telephone). Participants were randomized to complete one diary modality for 33 days before switching to the second modality for 33 days. The study was implemented in three urban HIV health care centers in the United States where participants were receiving services. Through diary data and qualitative interview data, we examined the feasibility and acceptability of the dairies and identified barriers and facilitators of dairy compliance. Results show high participant retention in the daily diary (93.4 %) and high compliance for the number of dairies completed (72.4 %). Internet diaries were preferred by 92 % of participants and completed at a significantly higher rate (77.5 %) than voice diaries (67.7 %). Facilitators included opportunities for self-reflection and cathartic sharing, monetary compensation, relationships with study staff, and daily reminders. Barriers included being busy or not having privacy at the time of reminders, forgetting, and falling asleep. Participants also described barriers and facilitators unique to each modality. Overall, both modalities were feasible and acceptable for use with our sample of HIV-infected MSM.

Maryland Alcohol Sales Tax and Sexually Transmitted Infections: A Natural Experiment

INTRODUCTION

Sexually transmitted infections are common causes of morbidity and mortality, including infertility and certain types of cancer. Alcohol tax increases may decrease sexually transmitted infection rates overall and differentially across population subgroups by decreasing alcohol consumption in general and prior to sex, thus decreasing sexual risk taking and sexually transmitted infection acquisition. This study investigated the effects of a Maryland increase in alcohol beverage sales tax on statewide gonorrhea and chlamydia rates overall and within age, gender, and race/ethnicity subpopulations.

METHODS

This study used an interrupted time series design, including multiple cross-state comparisons, to examine the effects of the 2011 alcohol tax increase in Maryland on chlamydia and gonorrhea cases reported to the U.S. National Notifiable Disease Surveillance System for January 2003 to December 2012 (N=120 repeated monthly observations, analyzed in 2015). Effects were assessed with Box-Jenkins autoregressive moving average models with structural parameters.

RESULTS

After the alcohol-specific sales tax increase, gonorrhea rates decreased 24% (95% CI=11%, 37%), resulting in 1,600 fewer statewide gonorrhea cases annually. Cohen's d indicated a substantial effect of the tax increase on gonorrhea rates (range across control group models, -1.25 to -1.42). The study did not find evidence of an effect on chlamydia or differential effects across age, race/ethnicity, or gender subgroups.

CONCLUSIONS

Results strengthen the evidence from prior studies of alcohol taxes influencing gonorrhea rates and extend health prevention effects from alcohol excise to sales taxes. Alcohol tax increases may be an efficient strategy for reducing sexually transmitted infections.

Brief report on ecological momentary assessment: everyday states predict HIV prevention behaviors

Background

Prevention behaviors help persons living with HIV (PLWH) to avoid transmitting HIV, and psychological variables have been found to predict HIV prevention behaviors. These variables have typically been measured using retrospective questionnaires about average psychological states over a period of time, which are likely to be biased by selective recall and interpretation. Measuring the same variables as momentary states, in the day-to-day context where they actually occur, may reveal different relationships to behavior.

Findings

21 PLWH completed daily surveys about momentary states and prevention behaviors. Brief, validated measures were used to assess control beliefs, mood, stress, coping, social support, stigma, knowledge, and motivation. We used multilevel models to predict prevention behaviors from momentary states the previous day, while controlling for the effect of multiple observations from the same person over time. Participants reported a moderate overall level of HIV prevention behaviors during the 6-month study. Although lapses in prevention were infrequent, there was room for improvement. Control beliefs, mood, and motivation had significant prospective effects on HIV prevention behaviors, rs = 0.07−0.21. Stress and coping had effects approaching significance.

Conclusions

Some momentary states predicted prevention behaviors, providing partial support for the motivational model. This finding supports past research showing effects of momentary states on behavior, and advances the science by testing multiple predictors. High within-sample diversity strengthened generalizability, but the overall sample size was small and the findings require replication. Future research should continue to examine the everyday experiences of PLWH as influences on their behavior.

Toward Development of Enhanced Preventive Interventions for HIV Sexual Risk among Alcohol-Using Populations: Confronting the 'Mere Pause from Thinking'

The papers in this issue detail state-of-the science knowledge regarding the role of alcohol use in HIV/AIDS risk, as well as offer suggestions for ways forward for behavioral HIV prevention for at-risk alcohol-using populations. In light of recent evidence suggesting that the anticipated uptake of the newer biomedical HIV prevention approaches, prominently including pre-exposure prophylaxis, has been stalled owing to a host of barriers, it has become ever more clear that behavioral prevention avenues must continue to receive due consideration as a viable HIV/AIDS prevention approach. The papers collected here make a valuable contribution to "combination prevention" efforts to curb HIV spread.

Research on the Effects of Alcohol and Sexual Arousal on Sexual Risk in Men who have Sex with Men: Implications for HIV Prevention Interventions

The purpose of this paper was to describe and appraise the research evidence on the effects of acute alcohol intoxication and sexual arousal on sexual risk behaviors in men who have sex with men (MSM) and to examine its implications for design of HIV prevention interventions that target MSM. Toward that end, the paper begins with a discussion of research on sexual arousal in men and alcohol and their acute effects on sexual behaviors. This is followed by a review of empirical evidence on the combined acute effects of alcohol and sexual arousal in heterosexual men (the large majority of studies) and then in MSM. The empirical evidence and related theoretical developments then are integrated to derive implications for developing effective HIV prevention interventions that target MSM.

Alcohol Expectancies and Inhibition Conflict as Moderators of the Alcohol-Unprotected Sex Relationship: Event-Level Findings from a Daily Diary Study Among Individuals Living with HIV in Cape Town, South Africa

Literature from sub-Saharan Africa and elsewhere supports a global association between alcohol and HIV risk. However, more rigorous studies using multiple event-level methods find mixed support for this association, suggesting the importance of examining potential moderators of this relationship. The present study explores the assumptions of alcohol expectancy theory and alcohol myopia theory as possible moderators that help elucidate the circumstances under which alcohol may affect individuals' ability to use a condom. Participants were 82 individuals (58 women, 24 men) living with HIV who completed daily phone interviews for 42 days which assessed daily sexual behavior and alcohol consumption. Logistic generalized estimating equation models were used to examine the potential moderating effects of inhibition conflict and sex-related alcohol outcome expectancies. The data provided some support for both theories and in some cases the moderation effects were stronger when both partners consumed alcohol.

Alcohol Myopia Revisited: Clarifying Aggression and Other Acts of Disinhibition Through a Distorted Lens

The alcohol myopia model (AMM; Steele & Josephs, 1990) is reviewed in light of its unique ability to account for a variety of alcohol and nonalcohol-related disinhibited behaviors, particularly aggression. The AMM posits that alcohol has a narrowing, or a "myopic," effect on one's ability to attend to competing instigatory and inhibitory cues. Disinhibited behavior is presumed to occur when attention is directed toward salient provocative or instigatory cues rather than inhibitory cues. AMM research is reviewed with regard to stress and anxiety, risky sexual behavior, drinking and driving, suicide, disinhibited eating, smoking, and alcohol-related aggression. The AMM is also expanded by proposing five key mechanisms (i.e., negative affect, angry affect, hostile cognitive rumination, self-awareness, and empathy) that are likely to explain how the model is specifically involved in the alcohol-aggression relation. Finally, a number of public health interventions, extrapolated from the AMM, are proposed to stimulate future research directed at reducing the prevalence of alcohol-related violence.

Smartphone self-monitoring to support self-management among people living with HIV: perceived benefits and theory of change from a mixed-methods randomized pilot study

BACKGROUND

Self-monitoring by mobile phone applications offers new opportunities to engage patients in self-management. Self-monitoring has not been examined thoroughly as a self-directed intervention strategy for self-management of multiple behaviors and states by people living with HIV (PLH).

METHODS

PLH (n = 50), primarily African American and Latino, were recruited from 2 AIDS services organizations and randomly assigned to daily smartphone (n = 34) or biweekly Web-survey only (n = 16) self-monitoring for 6 weeks. Smartphone self-monitoring included responding to brief surveys on medication adherence, mental health, substance use, and sexual risk behaviors, and brief text diaries on stressful events. Qualitative analyses examine biweekly open-ended user-experience interviews regarding perceived benefits and barriers of self-monitoring, and to elaborate a theoretical model for potential efficacy of self-monitoring to support self-management for multiple domains.

RESULTS

Self-monitoring functions include reflection for self-awareness, cues to action (reminders), reinforcements from self-tracking, and their potential effects on risk perceptions, motivations, skills, and behavioral activation states. Participants also reported therapeutic benefits related to self-expression for catharsis, nonjudgmental disclosure, and in-the-moment support. About one-third of participants reported that surveys were too long, frequent, or tedious. Some smartphone group participants suggested that daily self-monitoring was more beneficial than biweekly due to frequency and in-the-moment availability. About twice as many daily self-monitoring group participants reported increased awareness and behavior change support from self-monitoring compared with biweekly Web-survey only participants.

CONCLUSIONS

Self-monitoring is a potentially efficacious disruptive innovation for supporting self-management by PLH and for complementing other interventions, but more research is needed to confirm efficacy, adoption, and sustainability.

Daily Associations Between Drinking and Sex Among College Students: A Longitudinal Measurement Burst Design

Daily links between alcohol use and sexual behaviors were examined in a longitudinal study of college students. Hierarchical linear models predicted sexual behaviors by characteristics of persons (N=731; Level 3), semesters (N=4,345, Level 2), and days (N=56,372, Level 1). On a given day, consuming more drinks and binge drinking were associated with greater odds of kissing, touching, oral sex, and penetrative sex. Consistent with alcohol myopia and expectancy theories, associations between binge drinking and sexual behaviors were stronger for students not in romantic relationships, for students with stronger alcohol-sex expectancies, and for oral and penetrative sex. Findings suggest that within-day links between alcohol use and sexual behaviors are evident across college, with variations based on individual and relationship factors.

The price elasticity of demand for heroin: Matched longitudinal and experimental evidence

This paper reports estimates of the price elasticity of demand for heroin based on a newly constructed dataset. The dataset has two matched components concerning the same sample of regular heroin users: longitudinal information about real-world heroin demand (actual price and actual quantity at daily intervals for each heroin user in the sample) and experimental information about laboratory heroin demand (elicited by presenting the same heroin users with scenarios in a laboratory setting). Two empirical strategies are used to estimate the price elasticity of demand for heroin. The first strategy exploits the idiosyncratic variation in the price experienced by a heroin user over time that occurs in markets for illegal drugs. The second strategy exploits the experimentally induced variation in price experienced by a heroin user across experimental scenarios. Both empirical strategies result in the estimate that the conditional price elasticity of demand for heroin is approximately -0.80.

An exploration of weekly patterns in HIV-related behaviors: implications for successful interventions and future research

Recent studies have indicated weekly patterns of health behaviors and information seeking in areas such as diet and smoking cessation, but little information is available on whether similar patterns may exist in HIV. If such patterns do exist, there could be important implications for the timing of interventions for both prevention and care. This review provides a summary of the available literature on weekly patterns in HIV-relevant behaviors and existing interventions (including prevention and antiretroviral therapy [ART] adherence), and provides recommendations for additional research. Data were collected from published reports indexed from database inception through December 2014 and identified through PubMed and EBSCO. Only English language reports were included. Evidence of weekly patterns was found in information-seeking behaviors, risk behaviors, screening and care, and structuring of existing interventions, including ART adherence interventions. These patterns included increased interest in HIV-related information early in the week, weekend patterns of risk behavior among some populations, and interest in weekend and evening clinic hours. Literature on text messaging for ART adherence indicates that weekly short message service messages are the most effective. Implications for prevention and adherence interventions are discussed, and recommendations for future research are given.

Intoxication at last sexual intercourse and unprotected sex among HIV-positive and HIV-negative individuals in Uganda: an event-level analysis

This study examined, for the first time, the association between intoxication at last sexual intercourse and unprotected sex separately among HIV-positive and HIV-negative individuals. Data were derived from a nationally-representative survey of Uganda in 2011. Multivariable logistic regression analyses of the intoxication-unprotected sex association included adjustment for sociodemographic and behavioral covariates that were also examined as moderators of the association. Among HIV-positive individuals, intoxication was associated with unprotected sex, whereas among HIV-negative individuals, the intoxication-unprotected sex association was moderated by knowledge that condoms prevent HIV transmission. The odds of unprotected sex was 2.67 times greater among HIV-negative individuals who were unaware that condoms prevent HIV, an association not observed among those who possessed such knowledge. The results suggest that the intoxication-unprotected sex link be incorporated within Ugandan National HIV Prevention Strategies among HIV-positive and HIV-negative individuals. HIV-negative individuals who are unaware that condoms prevent HIV should be targeted for interventions focusing on increasing HIV transmission knowledge especially on the role of condoms in preventing the disease. The latter interventions should also identify those sociocultural and political beliefs about condom use that may serve as barriers to consistent condom use.

A counselor in your pocket: feasibility of mobile health tailored messages to support HIV medication adherence

PURPOSE

Medication adherence is a major challenge in HIV treatment. New mobile technologies such as smartphones facilitate the delivery of brief tailored messages to promote adherence. However, the best approach for tailoring messages is unknown. Persons living with HIV (PLWH) might be more receptive to some messages than others based on their current psychological state.

METHODS

We recruited 37 PLWH from a parent study of motivational states and adherence. Participants completed smartphone-based surveys at a random time every day for 2 weeks, then immediately received intervention or control tailored messages, depending on random assignment. After 2 weeks in the initial condition, participants received the other condition in a crossover design. Intervention messages were tailored to match PLWH's current psychological state based on five variables - control beliefs, mood, stress, coping, and social support. Control messages were tailored to create a mismatch between message framing and participants' current psychological state. We evaluated intervention feasibility based on acceptance, ease of use, and usefulness measures. We also used pilot randomized controlled trial methods to test the intervention's effect on adherence, which was measured using electronic caps that recorded pill-bottle openings.

RESULTS

Acceptance was high based on 76% enrollment and 85% satisfaction. Participants found the hardware and software easy to use. However, attrition was high at 59%, and usefulness ratings were slightly lower. The most common complaint was boredom. Unexpectedly, there was no difference between mismatched and matched messages' effects, but each group showed a 10%-15% improvement in adherence after crossing to the opposite study condition.

CONCLUSION

Although smartphone-based tailored messaging was feasible and participants had clinically meaningful improvements in adherence, the mechanisms of change require further study. Possible explanations might include novelty effects, increased receptiveness to new information after habituation, or pseudotailoring, three ways in which attentional processes can affect behavior.

Addressing predictors of HIV related risk behaviors: demographic and psychosocial profile of Iranian patients

BACKGROUND

For effective implementation of HIV-related behavioral interventions, better understanding the demographic characteristics of infected patients in relation with high-risk behavior profiles, physical and mental health are essential.

METHODS

In a cross-sectional descriptive study, 400 HIV infected patients from December 2011 through January 2013 were evaluated regarding their demographic features, and four selected subscales (high-risk behaviors, self-efficacy, well-being, and social participation). A validated questionnaire of 62 items was used for assessment.

RESULTS

Almost 33% of all participants were women, 28% were younger than 30 years old, and 43% were never married; 50% had no permanent jobs. Women, widowed participants, patients <30 years, and those with higher educational levels had higher mean HIV risk behavior scores. In simple and multiple linear regression models, women >50 years and <30 years had the highest scores (β=2.714, p<0.0001; β=2.00, p<0.001). Furthermore, male and illiterate patients had higher social participation scores while female and divorced participants had higher well-being and self-efficacy scores.

CONCLUSION

We propose that demographic features play a critical role in increasing engagement in HIV-related high-risk behaviors; these characteristics also affect patients' social participation, well-being and self-efficacy. High-risk behaviors and social participation scores among women of different age groups and the youth highlight the need for future age and gender-specific educational and behavioral interventions among them.

Alcohol use disorder, contexts of alcohol use, and the risk of HIV transmission among South African male patrons of shebeens

BACKGROUND

Shebeens in South Africa are settings in which alcohol use and sexual behavior often co-occur. The prevalence of alcohol use disorder (AUD), and the association between AUD, situations and settings, and sexual risk behavior, in shebeens remains unknown.

METHODS

Men (n=763; mean age=30; 98% Black African) were recruited from townships in Cape Town, South Africa and completed a self-administered survey that assessed alcohol use, sexual risk behaviors, and situations and settings of alcohol use. The Alcohol Use Disorder and Associated Disabilities Interview Schedule DSV-IV Version (AUDADIS-IV) was used to identify the likelihood of AUD. Bivariate regression analyses assessed whether screening for AUD predicted sexual risk behaviors. Multivariate regression analyses examined whether AUD and/or situations/settings predicted risk behaviors.

RESULTS

Nearly two-thirds of men (62%) endorsed sufficient criteria for AUD; 25%, 17%, and 20% were classified as having a mild, moderate, or severe AUD, respectively. AUD was associated with HIV risk such that men with AUD reported more unprotected sex than men without AUD. Analyses indicated that (a) individual (i.e., AUD) and (b) settings (i.e., frequency of having sex with a partner in a shebeen, tavern, or bottle store) interacted to predict unprotected sex.

CONCLUSIONS

The prevalence of AUD among shebeen patrons was high and was associated with unprotected sex. Findings suggest the need to integrate both individual and situational/setting factors to prevent HIV among patrons of shebeens.

Heterogeneous population effects of an alcohol excise tax increase on sexually transmitted infections morbidity

BACKGROUND AND AIMS

Alcohol taxes reduce population-level excessive alcohol use and alcohol-related morbidity and mortality, yet little is known about the distribution of the effects of alcohol taxation across race/ethnicity and age subgroups. We examined the race/ethnicity- and age group-specific effects of an excise alcohol tax increase on a common and routinely collected alcohol-related morbidity indicator, sexually transmitted infections.

METHODS

We used an interrupted time series design to examine the effect of a 2009 alcohol tax increase in Illinois, USA on new cases of two common sexually transmitted infections (chlamydia and gonorrhea) reported to the US National Notifiable Disease Surveillance System from January 2003 to December 2011 (n = 108 repeated monthly observations). We estimated the effects of the tax increase on infection rates in the general population and within specific race/ethnicity and age subgroups using mixed models accounting for temporal trends and median income.

RESULTS

Following the Illinois alcohol tax increase, state-wide rates of gonorrhea decreased 21% [95% confidence Interval (CI) = -25.7, -16.7] and chlamydia decreased 11% [95% CI = -17.8, -4.4], resulting in an estimated 3506 fewer gonorrhea infections and 5844 fewer chlamydia infections annually. The null hypothesis of homogenous effects by race/ethnicity and age was rejected (P < 0.0001). Significant reductions were observed among non-Hispanic blacks: gonorrhea rates decreased 25.6% (95% CI = -30.0, -21.0) and chlamydia rates decreased 14.7% (95% CI = -20.9, -8.0). Among non-Hispanics, point estimates suggest decreases were highest among 25-29-year-olds.

CONCLUSIONS

Increased alcohol taxes appear to reduce sexually transmitted infections, especially among subpopulations with high disease burdens, such as non-Hispanic blacks.

Heterosexual anal sex among female sex workers in high HIV prevalence states of India: need for comprehensive intervention

INTRODUCTION

Role of vaginal sex in heterosexual transmission of HIV has been investigated but that of heterosexual anal sex (HAS) is not fully understood. This paper examines practice of HAS among Female Sex Workers (FSWs) and its correlates in India where the HIV epidemic is being primarily driven by core groups like FSWs.

METHODS

Data for this paper are drawn from Round I survey of 9667 FSWs in the Integrated Biological and Behavioral Assessment (IBBA) from 23 districts of 4 high HIV prevalent states of India. Bivariate and multivariate analysis identified factors associated with HAS.

RESULTS

Ever having anal sex was reported by 11.9% FSWs (95% CI: 11.3%-12.6%). Typology (AOR 2.20, 95% CI 1.64-2.95) and literacy (AOR 1.28, 95% CI 1.10-1.49) were positively associated with practice of HAS. Longer duration in sex trade (AOR 1.69, 95% CI 1.44-1.99), entertaining larger number of clients the previous week (AOR 1.78, 95% CI 1.47-2.15), alcohol consumption (AOR 1.21, 95% CI 1.03-1.42) and inability to negotiate condom use (AOR 1.53, 95% CI 1.28-1.83) were also correlated with HAS. Self-risk perception for HIV (AOR 1.46, 95% CI 1.25-1.71) did not impede HAS. Although symptoms of sexually transmitted infections (STIs) in the last 12 months were associated with anal sex (AOR 1.39, 95% CI 1.13-1.72) there was no significant association between laboratory confirmed HIV and other STIs with HAS.

CONCLUSION

Practice of HAS by FSWs might significantly contribute to HIV transmission in India. This study also shows that despite self-risk perception for HIV, even literate FSWs with longer duration in sex work report HAS. General messages on condom use may not influence safe HAS. FSWs need to be targeted with specific messages on HIV transmission during anal sex. Women controlled prevention methods, such as rectal microbicides and vaginal microbicides are needed.

Sexual risk-taking mediates the association between impulsivity and acquisition of sexually transmitted infections among hazardously drinking incarcerated women

BACKGROUND

A growing literature has identified associations between impulsivity and negative behaviors such as sexual risk-taking among high-risk and/or vulnerable populations, but few studies have linked impulsivity to biological outcomes of sexual risk-taking. The main purpose of this study was to document associations among impulsivity, sexual risk-taking, and biological measures of sexually transmitted infection (STI+) in a sample of hazardously drinking incarcerated women.

METHODS

Two hundred forty-five hazardously drinking incarcerated women self-reported alcohol consumption and consequences, impulsivity, and sexual behavior.

RESULTS

Biological testing revealed a 22.9% prevalence rate for STI+. In this sample, sexual risk-taking fully mediated the association between impulsivity and likelihood of STI+. In addition, individuals reporting sexual activity with multiple partners were significantly more likely to test STI+ than those reporting sexual activity with a primary partner.

CONCLUSION

These results support previous research on impulsivity by demonstrating that impulsivity leads to STI+ through risky behavioral choices. These findings also extend prior work by documenting this association using biologically confirmed measures in a vulnerable female population that carries multiple risk factors and thus warrants increased research attention.

Substance use and HIV risk behavior among men who have sex with men: the role of sexual compulsivity

The relationship between substance use, sexual compulsivity and sexual risk behavior was assessed with a probability-based sample of men who have sex with men (MSM). Stimulant, poppers, erectile dysfunction medication (EDM), alcohol use, and sexual compulsivity were independently associated with higher odds of engaging in any serodiscordant unprotected anal intercourse (SDUAI). The association of sexual compulsivity with SDUAI was moderated by poppers and EDM use. Behavioral interventions are needed to optimize biomedical prevention of HIV among substance using MSM.

Depression, substance use and HIV risk in a probability sample of men who have sex with men

The persistent HIV epidemic among men who have sex with men (MSM) suggests that continued research on factors associated with risky sexual behavior is necessary. Drawing on prior literature, the role of depression and substance use in HIV risk is also inconclusive. Generalizability of past findings may also be limited to the extent that research has not employed probability samples. Here we report on one of the few probability samples of MSM to examine the role of depressive symptoms and substance use on risky sexual behavior (RSB). Multinomial logistic regression analysis suggested that depression and substance use are independently linked to our risk measure, such that those reporting high levels of depressive symptoms or substance use were more likely to report both unprotected receptive anal intercourse and unprotected insertive anal intercourse, and sex with a risky partner. Implications for prevention and treatment are discussed.

Feasibility and reliability of interactive voice response assessment of HIV medication adherence: research and clinical implications

BACKGROUND

There are well-documented negative consequences of nonadherence to HIV medications. Telephone-based interactive voice response (IVR) technologies may hold promise for assessing nonadherence in both research and clinical contexts; however, little psychometric research has been conducted on this topic.

OBJECTIVE

In the present pilot study, we test the feasibility and reliability of a simplified patient-initiated, daily IVR system with a convenience sample of HIV patients attending a university-affiliated infectious disease clinic.

METHODS

Participants were asked to call in to an IVR system to report adherence daily during 2 weeks of a larger prospective study. Response rates and patterns were analyzed for feasibility and compared to retrospective, self-report timeline follow-back (TLFB) adherence reporting.

RESULTS

The IVR protocol showed moderate feasibility, with participants reporting adherence behavior on 63.4% of days. However, agreement with TLFB data was low, particularly for days in which participants reported incomplete adherence.

CONCLUSIONS

The IVR protocol tested in the current trial shows some promise. Completion rates were higher than in previous trials. Future research is needed to further enhance the feasibility of IVR for HIV medication adherence and to compare responses to more objective measures on HIV adherence.

The effects of alcohol and sexual arousal on determinants of sexual risk in men who have sex with men

Primary prevention efforts aimed at sexual risk behaviors are critical. This experiment was designed to investigate the effects of alcohol intoxication and sexual arousal, as well as person variables of alcohol sex expectancies and attitudes toward condom use, on hypothesized determinants of sexual risk behaviors among men who have sex with men (MSM). The participants were 117 MSM aged 21-50 years who were randomly assigned to one of six separate experimental conditions created by the combination of beverage administration (water control, placebo or alcohol designed to raise blood alcohol level to .07%) and sexual arousal (low or high, manipulated by participants' viewing non-erotic or mildly erotic film clips). Participants attended two experimental sessions. The first session included completing questionnaires about beliefs about alcohol's effects on sex and attitudes toward condoms' effect on sexual pleasure. The second session involved the beverage condition and arousal manipulations. Following these, participants viewed and responded to two interactive videos depicting high sexual risk scenarios. Participants also completed the CARE, a measure of risk perceptions. The dependent variables were behavioral skills, intentions to have unsafe sex, and "risk exposure," derived from responses to the videos. The results of both planned and exploratory analyses showed general support for the hypothesized enhancement of alcohol's effects on sexual risk by both sexual arousal and expectancies. Also as predicted, condom attitudes showed direct relationships to risk exposure and intentions. Implications of the findings for models of alcohol's effects on sexual risk and for the development of HIV prevention interventions were discussed.

Prevalence and predictors of sexually transmitted infections in hazardously-drinking incarcerated women

Incarcerated women are at high risk for sexually transmitted infections. Left untreated, these infections can have severe adverse health effects. In this study the authors present prevalence rates of trichomonas, chlamydia, and gonorrhea, and factors related to having a sexually transmitted infection in a sample of 245 hazardously-drinking incarcerated women who reported heterosexual intercourse in the previous 3 months. Vaginal swabs were collected following the self-report baseline assessment. Participants averaged 34.0 (±8.8) years of age; 174 (71.3%) were non-Hispanic Caucasian, 47 (19.3%) were African-American, 17 (7.0%) were Hispanic, and 6 (2.5%) were of other racial or ethnic origins. Twenty-three percent of participants tested positive for chlamydia, trichomonas, or gonorrhea. Being African-American, more frequent sex with a casual partner, and reporting more than one male partner were significantly positively related to sexually transmitted infection, while more frequent sex with a main partner was inversely related. Due to the high rates of infection in this population, jail admission provides a public health opportunity to access a concentrated group of sexually transmitted infectious women. Sexually transmitted infection testing targeted at specific demographic factors, for instance younger age, will miss infected women. Risky sexual partnerships, as well as the benefit of maintaining stable main partnerships may be important topics during sexually transmitted infection prevention interventions.

Riskier sexual partners contribute to the increased rate of sexually transmitted diseases among youth with substance use disorders

BACKGROUND

Youth with alcohol or marijuana dependence or disorders (substance use disorders [SUDs]) are at increased risk of acquiring sexually transmitted diseases (STDs). Sexual partner characteristics may explain the relationship between SUD and STD.

METHODS

Clinical criteria for SUD, clinical STD diagnosis, and sexual partner characteristics were assessed among 15- to 24-year-old STD clinic attendees between 1999 and 2002 (n = 412). We used exact logistic regression and path analysis to examine the mediation effect of sexual partner characteristics (age discordance, incarceration, STD diagnosis, other partners, perceived alcohol problem, perceived marijuana problem, and a calculated composite measure) on the relationship between SUD and STD, adjusting for important demographics and condom use.

RESULTS

We found evidence of mediation by partner characteristics on the relationship between SUD and STD. For the logistic regression analysis, adding the partner characteristic composite reduced the strength of the association between SUD and STD from a statistically significant odds ratio of 1.7 (95% confidence interval = 1.0-2.7) to a statistically nonsignificant odds ratio of 1.5 (95% confidence interval = 0.9-2.5). In the path analysis, adding the partner characteristic composite reduced the significant direct effect of SUD on STD (β = 0.5, P = 0.04) to statistically nonsignificant effect (β = 0.1, P = 0.2). We estimated that 31% of the total effect of SUD on STD was attributable to the indirect path through the composite partner characteristic measure.

CONCLUSIONS

Even when controlling for demographics and condom use, partner characteristics partially explained the association between SUD and STD.

Incidence of sexually transmitted infections among hazardously drinking women after incarceration

INTRODUCTION AND BACKGROUND

At the time of incarceration, women have a high prevalence of sexually transmitted infections (STI). In the months after community release, women remain at high risk for new infections. This study assessed the rates and predictors of incident chlamydia, gonorrhea, and trichomoniasis in a sample of hazardously drinking women after incarceration.

METHODS

Self-reported behavioral data were collected from 245 incarcerated women. Vaginal swabs were collected at baseline, and 3- and 6-month time points and tested for chlamydia, gonorrhea, and trichomoniasis. Treatment was provided for all positive tests.

RESULTS

Participants' mean age was 34.1 years of age; 175 (71.4%) were Caucasian, 47 (19.2%) were African American, 17 (6.9%) were Hispanic, and 6 (2.4%) were of other ethnic origins. The STI incidence rate was estimated to be 30.5 (95% confidence interval, 21.3-43.5) new infections per 100 person-years. Number of male sex partners reported during follow-up was a significant (z = 2.16; p = .03) predictor of STI; each additional male sex partner increased the estimated hazard of STI by 1.26.

CONCLUSION

Incarcerated women who are hazardous drinkers are at high risk for STI in the months after their return to the community. In addition to testing and treatment during incarceration, post-release rescreening, education, partner treatment, and follow-up are recommended.

Alcohol-involved sexual risk behavior among heavy drinkers living with HIV/AIDS: negative affect, self-efficacy, and sexual craving

Evidence of the effects of negative affect (NA) and sexual craving on unprotected sexual activity remains scant. We hypothesized that NA and sexual craving modify the same day association between low self-efficacy to use condoms and unprotected anal or vaginal sex, and the same-day association between alcohol use during the 3 hours prior to sexual activity and unprotected sex. We used an electronic daily diary, drawing on a sample of 125 men and women recruited from an agency serving economically disadvantaged persons living with HIV/AIDS. Casual or steady partner type designation and perceived partner HIV serostatus were also examined. Findings support the hypothesized moderating effects of high NA and sexual craving on the association between low self-efficacy and unprotected sex, and the association between alcohol use and unprotected sex. Implications are discussed.

Spatial dimensions of research on alcohol and sexual risk: a case example from a Mumbai study

Alcohol's role in unprotected sex is an important issue in the spread of HIV. Research on alcohol use in many countries has found complex relationships between individual characteristics, places where people drink, and consumption patterns. Data on drinking and leisure time activities and locations from in-person surveys with 1,239 young men aged 18-29 living in low-income communities in Mumbai, India, were analyzed. For every pair of men, an index of association measured the degree of similarity in their reported activities in specific communities. Multidimensional scaling of the similarity matrix revealed men who engaged in similar activities in the same communities. Hierarchical grouping classified men based on their activity dimensions. The ten groups of men, distinguished by their activities in particular communities, also differed in alcohol consumption, number of non-spousal sex partners, and level of unprotected sex. Understanding where activities take place is important in designing venue-based interventions to reduce health risk behaviors leading to the spread of HIV/AIDS.

The relationships between states' DUI penalties and HIV-positive adults' drinking behaviors

Evidence that persons with HIV who reside in states with stricter DUI penalties drink less might suggest that changes to alcohol policy might improve the health of persons with HIV and reduce the rate of new infections. Using multi-level modeling and data from the national HIV Cost and Services Utilization Study, we examined how states' DUI-related fines, jail time, license suspension, and court-referred treatment/education policies were related to past month drinking/not (n = 2,255) and among drinkers (n = 1,117), drinking frequency, drinks per occasion, and engagement in frequent heavy drinking. Fine strictness was negatively related to all outcomes. Residents in states with court-referred treatment/education had more current drinkers. Results suggested that punitive DUI policies might curb a variety of drinking behaviors whereas harm reduction DUI policies (e.g., court treatment programs) might have been established in response to higher drinking rates.

Feasibility of a daily electronic survey to study prevention behavior with HIV-infected individuals

The daily experiences of persons living with HIV (PLWH) are important but under-studied as predictors of HIV prevention behavior. Ecological momentary assessment (EMA) is an intensive within-subjects data collection method that can be used to examine daily experiences. To determine whether PLWH would participate in EMA, we conducted a feasibility study with 21 PLWH. The method was acceptable to men and women from diverse backgrounds, with 81% (17/21) completing 2 months of daily surveys, and 67% (14/21) completing 6 months. Measures were completed on 72% of study days. Only 6% of records had missing data. Daily survey completion decreased over time. Participants reported that EMA was easy and did not influence their behaviors. Results suggest EMA is feasible with PLWH.

Alcohol as a correlate of unprotected sexual behavior among people living with HIV/AIDS: review and meta-analysis

The present investigation attempted to quantify the relationship between alcohol consumption and unprotected sexual behavior among people living with HIV/AIDS (PLWHA). A comprehensive search of the literature was performed to identify key studies on alcohol and sexual risk behavior among PLWHA, and three separate meta-analyses were conducted to examine associations between unprotected sex and (1) any alcohol consumption, (2) problematic drinking, and (3) alcohol use in sexual contexts. Based on 27 relevant studies, meta-analyses demonstrated that any alcohol consumption (OR = 1.63, CI = 1.39-1.91), problematic drinking (OR = 1.69, CI = 1.45-1.97), and alcohol use in sexual contexts (OR = 1.98, CI = 1.63-2.39) were all found to be significantly associated with unprotected sex among PLWHA. Taken together, these results suggest that there is a significant link between PLWHA's use of alcohol and their engagement in high-risk sexual behavior. These findings have implications for the development of interventions to reduce HIV transmission risk behavior in this population.

Does drinking lead to sex? Daily alcohol-sex behaviors and expectancies among college students

A within-person multilevel approach was used to model the links between alcohol use and sexual behavior among first-year college students, using up to 14 days of data for each person with occasions (Level 1, N = 2879 days) nested within people (Level 2, N = 218 people; 51.4% male). Between-persons (Level 2) effects were gender, relationship status, person means of alcohol use, and alcohol-sex expectancies for sexual affect and sexual drive. Within-person (Level 1) effects were weekend days, number of drinks consumed, and the interaction between drinks consumed and alcohol-sex expectancies. Independent of average alcohol use, consuming more drinks on a given day was associated with a greater likelihood of oral sex and with experiencing more positive consequences of sex that day. Significant Alcohol Use x Alcohol-Sex Expectancies interactions were found for oral sex and total sex behaviors, indicating that individuals with more positive expectancies were more likely to have sex after drinking. The negative association between drinks and condom use was at a trend level of significance. Results support the potential for promoting sexual health by focusing on cross-behavior expectancies among late adolescents.

Relationship of alcohol use and sexual risk taking among hazardously drinking incarcerated women: an event-level analysis

OBJECTIVE

To understand the association of alcohol use with sex and unprotected sex among hazardously drinking incarcerated women, we examined the relationship of these behaviors on any given day.

METHOD

Participants endorsed unprotected sex and hazardous alcohol consumption (four or more drinks at a time on at least 3 separate days in the previous 3 months or a score of 8 or above on the Alcohol Use Disorders Identification Test). Participants recalled behaviors in the 90 days before incarceration using the Timeline Followback method. Generalized estimating equation models estimated the effect of daily alcohol use and selected covariates on the odds of sexual-risk behavior.

RESULTS

The 245 participants averaged 34 years of age and were 71.4% white; 67.8% used cocaine. On most (84.7%) drinking days, women consumed four or more drinks. One hundred forty-one participants (57.6%) reported sex with only main partners, 10.6% with only casual partners, and 30.6% with both casual and main partners. The likelihood of having any sex (odds ratio = 1.78, p < .01) and unprotected sex (odds ratio = 1.95, p < .01) was higher on days when participants consumed alcohol compared with nondrinking days. However, when the analysis was restricted to days on which participants reported having sex, the odds of having unprotected sex was not significantly associated with drinking.

CONCLUSIONS

Among incarcerated women who reported hazardous drinking, alcohol use was associated with an increased likelihood of sexual activity and a concomitant increase in unprotected sex. However, use of alcohol was not significantly associated with condom use on days when participants were sexually active.

Secondary prevention of HIV infection: the current state of prevention for positives

PURPOSE OF REVIEW

To provide a state-of-the-science review of the literature on secondary prevention of HIV infection or 'prevention for positives' (PfP) interventions.

RECENT FINDINGS

Early work on PfP focused on understanding the dynamics of risky behavior among People Living with HIV/AIDS (PLWH) and on designing, implementing, and evaluating a limited number of interventions to promote safer sexual and drug use behavior in this population (i.e., PfP interventions). Previous meta-analyses demonstrated that PfP interventions can effectively promote safer behavior. However, the understanding of risk dynamics among PLWH and the extant number and breadth of effective PfP interventions were scant. Recent work has addressed some of these problems, yielding greater understanding of risk dynamics and providing additional, effective interventions. Still, only a modest number of recent, rigorously evaluated, effective interventions have been identified. New ideas for creating stronger, more integrated, and effective PfP interventions have emerged that will guide future intervention research and practice.

SUMMARY

There remains much to be done to understand why, when, and under what conditions PLWH practice risk. Substantial work also needs to be performed to design, implement, rigorously evaluate, and when effective, to disseminate widely, additional, evidence-based PfP interventions targeting diverse populations. Directing such interventions to populations of PLWH at greatest risk for transmission of HIV has the potential to yield significant impact on the pandemic.

Alcohol, helping young adults to have unprotected sex with casual partners: findings from a daily diary study of alcohol use and sexual behavior

PURPOSE

To examine the event-level association between alcohol consumption and the likelihood of unprotected sex among college-age young adults considering contextual factors of partner type and amount of alcohol consumed.

METHODS

A 30-day, Web-based, structured daily diary was used to collect daily reports of sexual behaviors and alcohol use from 116 sexually active young adults, yielding 2,764 diary records. Each day we assessed the prior evening's behavior regarding alcohol consumption, opportunities for sex, sexual intercourse, condom use, and contextual factors including type of sexual partner.

RESULTS

Based on multilevel models, drinking proximal to events of sexual intercourse increased the likelihood of unprotected sex with casual but not steady partners. For women there was a positive association between number of drinks and a greater likelihood of unprotected sex with casual partners but a negative association with steady partners. Drinking during situations involving opportunities for sex with casual partners increased the likelihood of sex. For women especially, drinking more increased the likelihood of sex occurring regardless of partner type.

CONCLUSIONS

Failure to assess the contextual determinants of the alcohol-unprotected sex association may result in underestimates of the magnitude of this association. These data highlight an important area for intervention with young adults: reducing alcohol-involved sexual risk behavior with casual partners, especially among women.