Alcohol, AIDS risks and sex industry clients: results from a Scottish study

A systematic review on the clustering and co-occurrence of multiple risk behaviours

BACKGROUND

Risk behaviours, such as smoking and physical inactivity account for up to two-thirds of all cardiovascular deaths, and are associated with substantial increased mortality in many conditions including cancer and diabetes. As risk behaviours are thought to co-occur in individuals we conducted a systematic review of studies addressing clustering or co-occurrence of risk behaviours and their predictors. As the main aim of the review was to inform public health policy in England we limited inclusion to studies conducted in the UK.

METHODS

Key databases were searched from 1990 to 2016. We included UK based cross-sectional and longitudinal studies that investigated risk behaviours such as smoking, physical inactivity, unhealthy diet. High heterogeneity precluded meta-analyses.

RESULTS

Thirty-seven studies were included in the review (32 cross-sectional and five longitudinal). Most studies investigated unhealthy diet, physical inactivity, alcohol misuse, and smoking. In general adult populations, there was relatively strong evidence of clustering between alcohol misuse and smoking; and unhealthy diet and smoking. For young adults, there was evidence of clustering between sexual risk behaviour and smoking, sexual risk behaviour and illicit drug use, and sexual risk behaviour and alcohol misuse. The strongest associations with co-occurrence and clustering of multiple risk behaviours were occupation (up to 4-fold increased odds in lower SES groups) and education (up to 5-fold increased odds in those with no qualifications).

CONCLUSIONS

Among general adult populations, alcohol misuse and smoking was the most commonly identified risk behaviour cluster. Among young adults, there was consistent evidence of clustering found between sexual risk behaviour and substance misuse. Socio-economic status was the strongest predictor of engaging in multiple risk behaviours. This suggests the potential for interventions targeting multiple risk behaviours either sequentially or concurrently particularly where there is evidence of clustering. In addition, there is potential for intervening at the social or environmental level due to the strong association with socio-economic status.

The social dynamics of safe sex practices among Canadian sex industry clients

Much of what we know about the safe sex practices of people who pay for sexual services (clients) remains firmly grounded in empirical and interpretive tendencies to overemphasise the causal link between social, cultural or individual characteristics and sexual decision-making. In this study we apply Adam Green's Bourdieu-inspired sexual fields theory to examine the ways in which safe sex practices are interdependently shaped by social, personal and interpersonal forces. Using data from 697 questionnaires and 24 semi-structured interviews with Canadian clients, we implemented a series of six additive logistic regression models and contextualised the results with the interview data to reveal the relational interdependencies of intra-psychic, macro, meso and micro-level factors related to safe sex practices. The questionnaire responses and interview data used in the study were gathered from a diverse sample of clients who were over the age of 19, had paid money for sexual services on one or more occasions during their lifetime and who resided in Canada at the time of participation. Our results illustrate the ways in which factors related to the venue where sexual acts take place, clients' relationships with commercial and non-commercial partners and personal choices related to substance use interdependently inform safe sex practices.

Binge-drinking in Britain as a Social and Cultural Phenomenon

Techniques and procedures of Strauss and Corbin's grounded theory were used to develop a conditional matrix on binge-drinking in Britain, reflecting data of 32 participants, aged between 22 and 58. The core category was `binge-drinking as a social and cultural phenomenon'. Results show the value of binge-drinking as an enjoyable way of socializing and counter-balancing the demands of daily hassles and routines. Intervening and contextual factors indicate fluctuations in binge-drinking behaviour and the social and cultural constraints that may operate, such as `no drink-driving', `not when the next day is a work day' and `not on one's own'.

Immunomodulation by nitrite inhalants may predispose abusers to AIDS and Kaposi's sarcoma

Epidemiological studies indicating that nitrite inhalant abuse is a co-factor in HIV infection and in Kaposi's sarcoma are supported by recent experimental studies, described in this review. Inhalation exposure to the nitrites produce a nonspecific cytotoxicity, depleting many cells of the immune system. Apparently distinct from this cytotoxicity, inhalation of the nitrites impairs a variety of immune mechanisms, affecting both humoral and cell-mediated immunity. In addition, the inhalant-increased macrophage production of the inflammatory cytokine tumor necrosis factor-alpha (TNF-alpha), can directly stimulate HIV replication and can also stimulate the growth of Kaposi's sarcoma cells. Thus, nitrite inhalants may impair immune resistance to infection and actively promote viral replication and tumor growth.

[Is there a correlation between alcohol drinking and sexual risk taking? A discussion of conceptional aspects exemplified by HIV infected men with homosexual behavior]

Does sexual risk behavior and alcohol consumption correlate or is sexual risk behavior due to alcohol consumption? These questions are controversially discussed in the literature. We investigated whether the two different methodological concepts (global association, e.g. not specific to the critical incident and situational association) cause these discrepancies in a sample of 64 HIV-infected gay men. There was no significant global association between alcohol consumption and sexual risk behavior. Using the situational approach, drinking was not related to sexual risk behavior. The combination of these two concepts may help to identify persons at risk.

Safer sex behavior and alcohol consumption. Research Group of the Swiss HIV Prevention Study

To test the hypothesis that safer sex procedures are less consistently observed by persons under the influence of alcohol, data from the Swiss human immunodeficiency virus (HIV) Prevention Study (HIPS) were evaluated. HIPS is a large prospective cohort study involving 724 HIV-negative and mainly heterosexual subjects who entertain casual sexual contacts. Of the 724 participants, 36% reported that they had had sex while under the influence of alcohol. Of this group, 31% indicated that safer sex procedures were neglected owing to the influence of alcohol. No significant differences with regard to unprotected sexual intercourse were found between subjects who combine sex and alcohol and those who do not. The same was found to be true among subjects with different levels of general alcohol consumption. However, a significant correlation was found between the intensity of alcohol consumption (i.e., the quantity of alcohol intake per sitting) and the incidence of unprotected sexual intercourse. These findings show that the relationship between alcohol consumption and safer sex is complex; they also emphasize the need for preventive efforts to reinforce safer sexual behavior, for example through individual counseling of persons at risk for HIV-infection.

Substance use and risky sexual behavior for exposure to HIV. Issues in methodology, interpretation, and prevention

Recent reports have suggested that the use of alcohol or drugs is related to sexual behavior that is high risk for HIV infection. If substance use leads to unsafe sexual activity, understanding the dynamics of this relationship can contribute to research and preventive and educational efforts to contain the spread of AIDS. In this article, we review research on the relationship between substance use and high-risk sexual behavior. We then consider the inherent limitations of the research designs used to study this relationship, outline some methodological concerns including measurement and sampling issues, and comment on causal interpretations of correlational research findings. We end with a consideration of potential avenues for future research and a discussion of implications of these findings for current AIDS prevention policies.

Alcohol and risky sex: in search of an elusive connection

Since the publication of the 1986 article by Stall, McKusick, Wiley, Coates and Ostrow, the conclusion that drinking alcohol prior to or during erotic encounters increases the probability of engaging in high-risk sexual behavior has been widely accepted, despite some contradictory findings from research on this hypothesis. This paper presents the results of tests of the alcohol/risky-sex hypothesis in a cohort of gay men in Flanders, Belgium. Failing to find evidence to support the hypothesis of a general effect of alcohol on sexual risk taking, we argue that previous conclusions on this matter must be viewed with extreme caution, especially in light of the implications that this failure to replicate has for AIDS prevention programs. Cultural, social, and methodological factors that could account for this failure to replicate are discussed in the context of a review of the literature on this hypothesis.