Unprotected casual sex and perceived risk of contracting HIV among drug users in Baltimore, Maryland: evaluating the influence of non-injection versus injection drug user status

Factors Associated with Sexual Risks and Risk of STIs, HIV and Other Blood-Borne Viruses Among Women Using Heroin and Other Drugs: A Systematic Literature Review

This systematic literature review identified factors associated with sexual risks related to sexually transmitted infections (STI), HIV and other blood-borne viruses (BBV) among women using heroin and other drugs. The search strategy included five databases (PubMed, EMBASE, PsycNET, Web of Science, Scopus), and PsycEXTRA for grey literature. Out of the 12,135 publications screened, 30 peer-reviewed articles were included. Most publications were cross-sectional (n = 25), quantitative (n = 23) and included 11,305 women. Factors identified were: (1) socio-demographics; (2) gender roles and violence against women; (3) substance use; (4) transactional sex; (5) partner characteristics, partner's drug use, and context of sex; (6) preferences, negotiation and availability of condoms; (7) HIV status and STIs; (8) number of sexual partners; (9) love and trust; (10) reproductive health and motherhood; and (11) risk awareness and perception of control. Overall, this review highlights important implications for future research and practice, and provides evidence for developing STI/BBV preventive strategies.

Predictive utility and measurement properties of the Strength of Implementation Intentions Scale (SIIS) for condom use

BACKGROUND

Implementation intentions are situation-linked action plans that increase health behaviors such as condom use. Few studies have measured the strength of implementation intentions, especially regarding condom use. Non-injection drug users are at high risk for HIV due to risky sexual practices. Substance use before sex may increase risky sexual behaviors, and implementation intentions are a promising, practical route for HIV prevention.

PURPOSE

This prospective study assessed the measurement properties of the newly developed Strength of Implementation Intentions Scale (SIIS) for condom use and investigated whether the SIIS predicted condom use one-year later. The study evaluated whether behavioral intentions and alcohol or methamphetamine use before sex modified the relationship between the SIIS and condom use.

METHODS

Participants were 590 non-injection drug users convicted of nonviolent drug offenses in court-mandated outpatient drug diversion programs. They completed self-directed computer assessments at baseline and at one-year follow-up. Measures included demographics, behavioral intentions to use condoms, the SIIS for condom use, alcohol and methamphetamine use before or during sex, and condom use. Psychometric properties, direct, and interaction effects of the SIIS were evaluated using structural equation modeling and general linear regressions.

RESULTS

The SIIS, behavioral intentions, and condom use were positively correlated and there was discriminant validity between all three constructs. In addition, the SIIS predicted condom use one-year later in this high-risk population. No significant interactions were detected.

CONCLUSIONS

The SIIS is predictive of condom use behavior, is psychometrically sound and distinct from behavioral intentions, and can be incorporated into HIV prevention interventions and used as a mediator variable. In addition, it can be used as an outcome measure where a follow-up is not feasible. The SIIS can also be tailored for additional HIV-related behaviors such as HIV-testing, adhering to antiretroviral medication, prescribing and adhering to pre-exposure prophylaxis, and other health behaviors.

Reducing non-injection drug use in HIV primary care: A randomized trial of brief motivational interviewing, with and without HealthCall, a technology-based enhancement

AIMS

In HIV-infected individuals, non-injection drug use (NIDU) compromises many health outcomes. In HIV primary care, the efficacy of brief motivational interviewing (MI) to reduce NIDU is unknown, and drug users may need greater intervention. We designed an enhancement to MI, HealthCall (HC), for daily patient self-monitoring calls to an interactive voice response (IVR) phone system, and provided participants with periodic personalized feedback. To reduce NIDU among HIV primary care patients, we compared the efficacy of MI+HealthCall to MI-only and an educational control condition.

DESIGN

Participants age >18 with >4days of NIDU during the prior 30days were recruited from large urban HIV primary care clinics. Of the 240 participants, 83 were randomly assigned to control, 77 to MI-only, and 80 to MI+HC. Counselors provided educational control, MI-only or MI+HC at baseline. At 30 and 60days (end-of-treatment), counselors briefly discussed drug use, moods and health behaviors, using HealthCall-generated graphs with MI+HC patients. Primary outcomes (last 30days) were number of days used primary drug (NumDU), and total quantity of primary drug used (dollar amount spent; QuantU), derived from the Time-Line Follow-Back.

FINDINGS

Across all groups, at end-of-treatment, frequency and quantity of NIDU decreased, with significantly greater reductions in the MI-Only group. A twelve-month post-treatment follow-up indicated sustained benefits of MI+HC and MI-only relative to control.

CONCLUSIONS

Brief interventions can be successfully used to reduce non-injection drug use in HIV primary care. IVR-based technology may not be sufficiently engaging to be effective. Future studies should investigate mobile technology to deliver a more engaging version of HealthCall to diverse substance abusing populations.

The development of a new condom use expectancy scale for at-risk adults

RATIONALE

Engaging in risky sexual behavior increases transmission of HIV.

OBJECTIVE

The present study used previously elicited salient outcomes of condom use to examine the factor structure and test the predictive utility of a condom use expectancy scale.

METHODS

Participants were drug offenders from court ordered drug diversion programs in Southern California. The condom use expectancy scale consisted of three factors: positive condom outcome items, negative condom outcome items, and safe sex items.

RESULTS

The factor analysis confirmed the three-factor structure. Positive condom use expectancies were a significant predictor of both condom use and intentions to use condoms, and negative condom use expectancies predicted non-use of condoms.

CONCLUSION

Understanding conditions of condom use can aid public health researchers and practitioners to better identify those in need of HIV prevention and how to target those needs.

Differences in sociodemographic, drug use and health characteristics between never, former and current injecting, problematic hard-drug users in the Netherlands

Background

Injecting drug users are at increased risk for harmful effects compared to non-injecting drug users. Some studies have focused on differences in characteristics between these two groups (e.g., housing, overall health). However, no study has investigated the specific Dutch situation which in the last years has seen a decrease in homelessness among problematic hard-drug users and an increasing focus on physical health in low-threshold addiction care. The purpose of this study was to determine differences in sociodemographic, drug use and health characteristics between never-injecting (NIDUs), former-injecting (FIDUs) and current-injecting drug users (IDUs) and describe injecting practices.

Methods

A total of 202 problematic hard-drug users (NIDU = 64; FIDU = 76; IDU = 62) were recruited from 22 low-threshold care facilities, including drug consumption rooms, methadone maintenance treatment, heroin-assisted therapy, day shelter and/or night shelter, supported housing and day activity centres. Data were collected on-site through structured face-to-face interviews.

Results

Results indicate that IDUs represented a separate group of problematic hard-drug users, with distinct sociodemographic and drug use characteristics. Overall, IDUs appeared to be the group with least favourable characteristics (unstable housing/homelessness, illegal activities, polydrug use) and NIDUs appeared to have the most favourable characteristics (stable housing, help with debts, less polydrug use). The FIDU group lies somewhere in between. The three groups did not differ significantly in terms of health. Regarding injecting practices, results showed that majority of IDUs had injected drugs for over 10 years and IDUs injected heroin, cocaine, amphetamine and/or methadone in the past 6 months. Sharing syringes was not common. A quarter reported public injecting.

Conclusions

Unstable housing and homelessness are related to (former) injecting drug use, and stable housing is related to never-injecting drug use. Our study suggests that the number of ‘new’ IDUs is low. However, public injecting among IDUs is not uncommon and is associated with unstable housing. This emphasizes the potential of housing projects as a component of harm reduction measures. Therefore, prevention of (risks associated with) injecting drug use and supported housing programmes for problematic hard-drug users deserve the continuous attention of policymakers and professionals in low-threshold addiction care.

Should associations between HIV-related risk perceptions and behaviors or intentions be positive or negative?

Risk perceptions are important in HIV research and interventions; mixed results were found between HIV-related perceptions and behaviors. We interviewed 377 sexually active injecting drug users in China, finding mixed associations between HIV-related risk perception assessed by two general measures and two previous risk behaviors (syringe sharing: p<.05; unprotected sex: p>.05) – partially supporting the ‘reflective hypothesis’ that reflection on previous behaviors increases risk perceptions. When we use specific measures for risk perceptions (HIV transmission via unprotected sex with specific types of sex partner and via syringe sharing) and use behavioral intention to adopt protective risk behaviors (condom use and avoid syringe sharing totally) as dependent variables, positive significant associations were observed – supporting the motivational hypothesis that risk perceptions motivate one to adopt protective behaviors. The direction and significance of the associations of concern depends on types of measures used. It has important implications on research design, data interpretation and services.

Major Depression and Risky Sexual Behavior among Substance Dependent Patients: The Moderating Roles of Distress Tolerance and Gender

The goal of the present study was to examine the main and interactive effects of major depressive disorder (MDD), distress tolerance (DT), and gender on multiple indices of risky sexual behavior (RSB) within a sample of 185 substance dependent patients in residential substance abuse treatment. Participants were interviewed to establish current MDD (as well as other Axis I and II diagnoses) and completed a behavioral measure of DT, the Paced Auditory Serial Addition Task - Computerized Version. Results provided evidence of a MDD × DT interaction for number of different past year commercial and casual sexual partners with which penetrative sex occurred. Post-hoc analyses demonstrated that participants with current MDD and low DT reported the greatest number of commercial and casual sexual partners. Results highlight one psychological vulnerability (DT) that may improve our understanding of the complex relationship between depression and RSB. Treatment implications of findings are discussed.

Knowledge of HIV transmission through breast milk among drug-dependent pregnant women

Abstract The current study examined the correlates of knowledge about human immunodeficiency virus (HIV) transmission through breast milk among drug-dependent pregnant women. There is a tremendous need to examine the knowledge about HIV transmission through breastfeeding among this largely understudied, but high-risk subset of pregnant women in order to minimize the extent to which they pass HIV to their children after giving birth. Participants included 97 pregnant women from Baltimore, MD, USA. Prevalence of drug use over the last 6 months included 37.1% reporting smoking marijuana, 36.1% injecting heroin, and 67.0% smoking crack. When asked whether HIV could be transmitted through breast milk, 72 women (74.2%) answered correctly. Our results indicate that the overall knowledge about transmission through breast milk is relatively low. Furthermore, participants who smoked crack during the past 6 months and participants who were white were significantly less likely to have correct knowledge about this topic. Our findings have important implications with regard to preventive interventions for this population. Future research is needed to determine how to best modify these interventions to address the specific needs of drug-dependent pregnant women, and how to specifically target white women and women who smoke crack.

Differences in self-reported discrimination by primary type of drug used among New York City drug users

BACKGROUND

Illicit drug users experience various forms of discrimination which may vary by type of drug used, as there are different levels of stigma associated with different types of drugs.

OBJECTIVES

This study investigated self-report of perceived discrimination by primary type of drug used.

METHODS

This analysis used data from "Social Ties Associated with Risk of Transition into Injection Drug Use" (START), a cross-sectional study of recently initiated injection drug users (IDUs) and prospective study of heroin/crack/cocaine-using non-IDUs (n = 652). Using log binomial regression, the relationship between primary drug used (i.e., single drug used most often) with discrimination due to drug use was examined.

RESULTS

Heroin users were significantly more likely (Prevalence ratio (PR): 1.52 (95% Confidence interval (CI): 1.15-2.07)) to report discrimination due to drug use compared to cocaine users.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

More research is needed to understand the mechanism through which discrimination affects heroin users, and its potential relation with other discrimination-related outcomes, namely depression and drug treatment.

HealthCall: technology-based extension of motivational interviewing to reduce non-injection drug use in HIV primary care patients - a pilot study

To reduce non-injection drug use (NIDU) among HIV primary care patients, more than a single brief intervention may be needed, but clinic resources are often too limited for extended interventions. To extend brief motivational interviewing (MI) to reduce NIDU, we designed and conducted a pilot study of "HealthCall," consisting of brief (1-3 minutes) daily patient calls reporting NIDU and health behaviors to a telephone-based interactive voice response (IVR) system, which provided data for subsequent personalized feedback. Urban HIV adult clinic patients reporting ≥4 days of NIDU in the previous month were randomized to two groups: MI-only (n=20) and MI+HealthCall (n=20). At 30 and 60 days, patients were assessed and briefly discussed their NIDU behaviors with their counselors. The outcome was the number of days patients used their primary drug in the prior 30 days. Medical marijuana issues precluded HealthCall with patients whose primary substance was marijuana (n=7); excluding these, 33 remained, of whom 28 patients (MI-only n=17; MI+HealthCall n=11) provided post-treatment data for analysis. Time significantly predicted reduction in "days used" in both groups (p<0.0001). At 60 days, between-group differences approached trend level, with an effect size of 0.62 favoring the MI+HealthCall arm. This pilot study suggests that HealthCall is feasible and acceptable to patients in resource-limited HIV primary care settings and can extend patient involvement in brief intervention with little additional staff time. A larger efficacy trial of HealthCall for NIDU-reduction in such settings is warranted.

A review of factors associated with unprotected sex among adult women in the United States

OBJECTIVE

To provide an updated review of research since 2005 on factors associated with unprotected sex among women in the United States.

DATA SOURCES

PubMed, CINAHL, and PsychINFO were searched from January 2006 through April 2011 using the terms unsafe sex, sexual risk taking, contraception, contraception behavior, birth control, condoms, and condom utilization.

STUDY SELECTION

Inclusion criteria included studies written in English on adult women in the United States age ≥ 18. Forty-five publications met inclusion criteria.

DATA EXTRACTION

All factors associated with engagement in unprotected sex are presented.

DATA SYNTHESIS

Unprotected sex has been associated with increasing age, being married, establishment of trust, recent experience of intimate partner violence, contraceptive side effects, infrequent sexual intercourse, and decreased arousal and pleasure due to contraceptive use. Religion, depression, history of abortion, number of children, having children, and number of pregnancies have not been associated with unprotected sex in recent studies. Several other variables have been studied with mixed results, possibly due to differences in research methods and sample characteristics.

CONCLUSIONS

More research is needed to elucidate the impact of cultural factors, relationship factors, attitude to pregnancy and motherhood, and reproductive coercion on prevention of pregnancy and sexually transmitted infections. Nurses can lead research on these topics and implement evidence-based practice based on study findings.

Problem recognition, intention to stop use, and treatment use among regular heroin injectors

This study investigated frequency of recent use as an explanatory variable in problem recognition and intention to stop use among regular injection heroin users. Data from the NEURO-HIV Epidemiologic Study, an investigation of neuropsychological and social-behavioral risk factors for HIV and hepatitis A, B, and C among injection and noninjection drug users, were used in the analyses. Participants (N = 337) consisted of those who reported injecting heroin daily or nearly daily for a period of 3 months. Multiple linear regression analysis revealed that frequency of recent injection drug use predicted problem recognition (β = .17), but not intention to stop use; although marginal, being female (β = .15), and homeless (β = .14) contributed to intention to stop use. Past 6-month treatment participation was 48%, and current treatment enrollment was 26% among study participants. This study highlights the importance of capitalizing on injection drug users' recent use as a mechanism for treatment interventions.

Progress in HIV reduction and prevention among injection and noninjection drug users

Substantial progress has been made in reducing HIV among injection drug users (IDUs) in the United States, despite political and social resistance that reduced resources and restricted access to services. The record for HIV prevention among noninjecting drug users is less developed, although they are more numerous than IDUs. Newer treatments for opiate and alcohol abuse can now be integrated into primary HIV care; treatment for stimulant abuse is less developed. All drug users present challenges for newer HIV prevention strategies (eg, "test and treat," nonoccupational postexposure prophylaxis and preexposure prophylaxis, contingency management, and conditional cash transfer). A comprehensive HIV prevention program that includes multicomponent multilevel approaches (ie, individual, network, structural) has been effective in HIV prevention among IDUs. Expanding these approaches to noninjecting drug users, especially those at highest risk (eg, minority men who have sex with men) and incorporating these newer approaches is a public health priority.

Non-injection drug use and HIV disease progression in the era of combination antiretroviral therapy

Little is known about the effects of non-injection drug use (NIDU) on HIV antiretroviral treatment outcomes. We conducted a systematic literature search and identified nine publications from prospective cohort studies investigating the relationship between NIDU and clinical HIV disease progression. Hazard ratios from studies estimating the effect of drug use on time to AIDS-related mortality ranged from 0.89 to 3.61, and only two of these were statistically significant. Hazard ratios from studies assessing time to an AIDS-defining event ranged from 1.19 to 2.51, with 8 of the 14 estimates falling between 1.55 and 1.65 regardless of drug use definition and measurement of use or frequency. It is suggested that NIDU may have a moderate effect of increasing the risk of progression to AIDS, but its impact on AIDS-related mortality is uncertain. NIDU may affect HIV antiretroviral treatment outcomes primarily through interaction with antiretroviral therapy and, to a lesser extent, through immune modulation and deterioration of general health. The limitations about published studies are discussed, and future perspectives on research on this topic are provided.

Gender differences in high risk sexual behaviors and injection practices associated with perceived HIV risk among injection drug users

This study compared male and female injection drug users (IDUs) on perceived risk of contracting HIV and examined the associations between risk perceptions and sharing injection drugs or equipment, engaging in casual sex, and engaging in commercial sex. We used baseline data from 271 IDUs recruited between 2000 and 2005 from the Baltimore, Maryland site of the International Neurobehavioral HIV Study. We found that although there was no significant difference in levels of perceived risk between males and females, males reported significantly more casual sex, whereas females reported more commercial sex. Logistic regression analyses with the entire sample indicated that sharing of injection drugs or equipment was consistently associated with greater perceived risk. We also found a significant interaction between gender and having had casual sex, such that females who had engaged in casual sex were significantly more likely to perceive that they were at greater risk for contracting HIV. Our results suggest that male IDUs should be targeted for HIV risk-reduction programs focusing on casual and commercial sex.