Alcohol and drug use and related disorders: An underrecognized health issue among adolescents and young adults attending sexually transmitted disease clinics

Acceptability of integrating mental health and substance use care within sexual health services among young sexual and gender minority men in Vancouver, Canada

BACKGROUND

Despite well-established evidence showing that young sexual and gender minority (SGM) men experience disproportionate mental health and substance use inequities, few sexual health services provide mental health and substance use care. This qualitative study examined the experiences and perspectives about integrated care models within sexual health services among young SGM men experiencing mental health and substance use challenges.

METHODS

Semi-structured interviews were conducted with 50 SGM men aged 18-30 years who reported using substances with sex in Vancouver, Canada. Interviews were analyzed using thematic analysis.

RESULTS

Three themes were identified: 1) participants asserted that their sexual health, mental health and substance use-related health needs were interrelated and that not addressing all three concurrently could result in even more negative health outcomes. These concurrent health needs were described as stemming from the oppressive social conditions in which SGM men live. 2) Although sexual health clinics were considered a safe place to discuss sexual health needs, participants reported not being invited by health providers to engage in discussions about their mental health and substance use health-related needs. Participants also perceived how stigmas associated with mental health and substance use limited their ability to express and receive support. 3) Participants identified key characteristics they preferred and wanted within integrated care, including training for health providers on mental health and SGM men's health and connections (e.g., referral processes) between services. Participants also recommended integrating social support programs to help them address SGM-related social challenges.

CONCLUSION

Our findings highlight that SGM men's sexual health, mental health and substance use-related health needs and preferences are interrelated and should be addressed together. Tailored training and resources as well as structural adaptations to improve communication channels and collaborative connections between health providers are required to facilitate the development of integrated care for young SGM men.

Using Machine Learning to Identify Predictors of Sexually Transmitted Infections Over Time Among Young People Living With or at Risk for HIV Who Participated in ATN Protocols 147, 148, and 149

BACKGROUND

Sexually transmitted infections (STIs) among youth aged 12 to 24 years have doubled in the last 13 years, accounting for 50% of STIs nationally. We need to identify predictors of STI among youth in urban HIV epicenters.

METHODS

Sexual and gender minority (gay, bisexual, transgender, gender-diverse) and other youth with multiple life stressors (homelessness, incarceration, substance use, mental health disorders) were recruited from 13 sites in Los Angeles and New Orleans (N = 1482). Self-reports and rapid diagnostic tests for STI, HIV, and drug use were conducted at 4-month intervals for up to 24 months. Machine learning was used to identify predictors of time until new STI (including a new HIV diagnosis).

RESULTS

At recruitment, 23.9% of youth had a current or past STI. Over 24 months, 19.3% tested positive for a new STI. Heterosexual males had the lowest STI rate (12%); African American youth were 23% more likely to acquire an STI compared with peers of other ethnicities. Time to STI was best predicted by attending group sex venues or parties, moderate but not high dating app use, and past STI and HIV seropositive status.

CONCLUSIONS

Sexually transmitted infections are concentrated among a subset of young people at highest risk. The best predictors of youth's risk are their sexual environments and networks. Machine learning will allow the next generation of research on predictive patterns of risk to be more robust.

Relationship Between Alcohol Consumption and Risky Sexual Behaviors Among Adolescents and Young Adults: A Meta-Analysis

Objectives: Adolescents exposed to alcohol have increased risky sexual behaviors (RSBs); however, the association between alcohol consumption and RSBs has to be systematically and quantitatively reviewed. We conducted a meta-analysis of the literature to systematically and quantitatively review the association between alcohol consumption and RSBs in adolescents and young adults. Methods: We searched for qualified articles published from 2000 to 2020 and calculated pooled odds ratios (ORs) using the random-effect model. We also conducted meta-regression and sensitivity analyses to identify potential heterogeneity moderators. Results: The meta-analysis of 50 studies involving 465,595 adolescents and young adults indicated that alcohol consumption was significantly associated with early sexual initiation (OR = 1.958, 95% confidence interval (CI) = 1.635-2.346), inconsistent condom use (OR = 1.228, 95% CI = 1.114-1.354), and having multiple sexual partners (OR = 1.722, 95% CI = 1.525-1.945). Conclusion: Alcohol consumption is strongly associated with RSBs, including early sexual initiation, inconsistent condom use, and multiple sexual partners among adolescents and young adults. To prevent the adverse consequences of alcohol consumption, drinking prevention programs should be initiated at an early age and supported by homes, schools, and communities.

Randomized controlled trial to test the efficacy of a brief, communication-based, substance use preventive intervention for parents of adolescents: Protocol for the SUPPER Project (Substance Use Prevention Promoted by Eating family meals Regularly)

Background

Substance use among adolescents in the U.S. is associated with adverse physical and mental health outcomes in the long-term. Universal youth-focused substance use prevention programs have demonstrated effectiveness but are often not sustainable due to the significant amount of time, effort, and resources required. We describe a trial protocol for a brief, low-participant-burden intervention to improve substance use-specific parent-child communication through the promotion of family meals and increased parental engagement.

Methods

This study is a parallel-group randomized controlled trial designed to assess the efficacy of a 13-week intervention. A total of 500 dyads of parents and their 5^th-7^th grade children are recruited from across Massachusetts. Dyads are randomized to the intervention or attention-control condition using block urn randomization, based on child grade, gender, and school. Parents/guardians in the substance use preventive intervention arm receive a short handbook, attend two meetings with an interventionist, and receive two SMS messages per week. Parents/guardians in the control arm receive the same dose but with content focused on nutrition, physical activity, and weight stigma. Participant dyads submit videos of family meals, audio recordings of prompted conversations, and quantitative surveys over an 18-month period (baseline, 3, 6, 12, 18 months post-intervention). The primary outcomes measure the quantity and quality of parent-child substance use conversations and proximal child indicators (i.e., substance use attitudes and expectancies, affiliation with substance-using peers, and intentions and willingness to use substances). The secondary outcome is child substance use initiation.

Discussion

This is a novel, brief, communication-focused intervention for parents/guardians that was designed to reduce participant burden. The intervention has the potential to improve parent-child engagement and communication and conversations about substance use specifically and decrease child substance use risk factors and substance use initiation.

Trial registration

ClinicalTrials.gov NCT03925220. Registered on 24 April 2019.

Computer delivered intervention for alcohol and sexual risk reduction among women attending an urban sexually transmitted infection clinic: A randomized controlled trial

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Unhealthy alcohol use is prevalent among women attending STI clinics.

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We tested whether CBI or CBI-IVR-TM, reduced alcohol use among women in this setting.

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Neither CBI nor CBI-IVR-TM reduced alcohol use more than control.

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2/3 of women had an alcohol use disorder, 65% substance use, 28% depressive symptoms.

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CBI is insufficient for alcohol reduction in this high severity, high comorbidity setting.

Objective

We sought to determine if a computer delivered brief alcohol intervention (CBI) with or without interactive voice response counseling and text messages (CBI-IVR-TM), reduced alcohol use and sexual risk behaviors compared to attention control.

Methods

We conducted a 3-arm RCT among women (n = 439) recruited from Baltimore City Sexually Transmitted Infection (STI) Clinics. Eligibility included: 1) consumption of >7 drinks per week or 2) ≥2 episodes of heavy episodic drinking or ≥2 episodes of sex under the influence of alcohol in the prior three months. Research assessments conducted at baseline, 3, 6 and 12 months included a 30-day Timeline Followback querying daily alcohol use, drug use, and sexual activity. We used the MINI International Neuropsychiatric Interview-DSM-IV to ascertain drinking severity. Primary alcohol outcomes included: drinking days, heavy drinking days, drinks per drinking day. Secondary sexual risk outcomes included number of sexual partners, days of condomless sex, and days of condomless sex under the influence of drugs and alcohol.

Results

Median age was 31 (IQR 25–44 years), 88% were African American, 65% reported current recreational drug use, and 26% endorsed depressive symptoms. On the MINI 66% met criteria for alcohol use disorder (49% alcohol dependence, 18% abuse). At follow-up, all three groups reduced drinking days, heavy drinking days, drinks per drinking day and drinks per week with no significant differences between study arms. There was no difference in sexual risk outcomes among the groups.

Conclusions

 Among women attending an urban STI clinic single session CBI with or without IVR and text message boosters was insufficient to reduce unhealthy alcohol use or sexual risk behaviors beyond control. The high severity of alcohol use and the prevalence of mental health symptoms and other substance use comorbidity underscores the importance of developing programs that address not only alcohol use but other determinants of STI risk among women.

Improving the Sexual Health of Young People (under 25) in High-Risk Populations: A Systematic Review of Behavioural and Psychosocial Interventions

Background: Ensuring young people experience good sexual health is a key public health concern, yet some vulnerable groups of young people remain at higher risk of poor sexual health. These individuals require additional support to achieve good sexual health but the best way to provide this remains needs to be better understood. Methods: We searched for randomised controlled trials of behavioural and psychosocial interventions aimed at promoting sexual health in high-risk young populations. Outcomes of interest were indicators of sexual health (e.g., condom use, attitudes to contraception, knowledge of risk). Participants were under 25 years old and in one of the following high-risk groups: alcohol and other drug use; ethnic minority; homeless; justice-involved; LGBTQI+; mental ill-health; or out-of-home care. Results: Twenty-eight papers from 26 trials met our inclusion criteria, with all but one conducted in North America. Condom use was the most frequently reported outcome measure along with knowledge and attitudes towards sexual health but considerable differences in measures used made comparisons across studies difficult. Change in knowledge and attitudes did not consistently result in long-term change in behaviours. Conclusions: There remains a dearth of research undertaken outside of North America across all high-risk groups of young people. Future interventions should address sexual health more broadly than just the absence of negative biological outcomes, with LGBTQI+, homeless and mental ill-health populations targeted for such work. An international consensus on outcome measures would support the research field going forward, making future meta-analyses possible.

Spatial Distribution and Factors Associated with Multiple Sexual Partnerships among Reproductive-Aged Men in Ethiopia: A Spatial and Mixed-Effect Analysis of the 2016 Ethiopian Demographic and Health Survey

Background

Though multiple sexual partnerships (MSPs) increase the risk of acquiring sexually transmitted diseases, such as HIV/AIDS, they are still common in sub-Saharan Africa, particularly in Ethiopia. Therefore, this study aimed to investigate spatial distribution and factors associated with MSPs among reproductive-age men in Ethiopia.

Methods

This study was based on Ethiopian Demographic and Health Survey 2016 data. A total weighted sample of 12,688 men aged 15–59 years was included. Spatial analysis was conducted using Arc GIS 10.3 and SaTScan 9.6 statistical software. Mixed-effect logistic regression analysis was used to estimate the association between MSPs and independent variables. Variables with p<0.05 on multivariable mixed-effect analysis were considered significant predictors of MSPs.

Results

MSPs had significant variations across the country (global Moran’s I=0.109, p<0.001). The primary-cluster spatial window was located in the southwest Oromia and Somalia regions, withrelative risk of 3 and log-likelihood ratio of 24.49 (P<0.001). Age 20–29 years (AOR 2.79, 95% CI 1.83–4.26), 30–39 years (AOR 4.04, 95% CI 2.48–6.58), and 40–59 years (AOR 7.13, 95% CI 4.36–11.68), never married (AOR 1.54, 95% CI 1.13–2.08), femle-headed household (AOR 1.90, 95% CI 1.48–2.44), Internet usage (AOR 1.62, 95% CI 1.21–2.17), ever chewing khat (AOR 1.72, 95% CI 1.37–2.18), ever drinking alcohol (AOR 2.31, 95% CI 1.74–3.08), and being from regions other than Tigray, Harari, and Dire Dawa were significant factors associated with increased odds of MSPs.

Conclusion

MSPs showed significant variations across the country, with the primary-cluster spatial window located in Oromia and Somalia regions. Therefore, special attention should be paid to high-risk regions and groups, particularly those who are unmarried and substance users, to decrease MSPs and their serious consequences, such as HIV and other sexually transmitted infections.

Intersections between Young Women's Racial/Ethnic Identities and Sexual Orientation on Rates of Sexual Violence and Substance Use

Background

Little is known about whether there are differences in rates of sexual violence and its association with substance use based on women's identities, specifically the intersection of their race/ethnicity and sexual orientation.

Method

Women (N = 546; 18 to 29 years of age) recruited from a reproductive healthcare clinic reported their race, ethnicity, sexual orientation, sexual violence history and substance use. Five logistic regressions examined (a) rates of sexual violence, and (b) the strength of the associations between sexual violence and four substance use outcomes (heavy alcohol use, marijuana use, cigarette use, number of cigarettes used) based on sexual orientation. Subsequent logistic regressions examined race/ethnicity as a moderator of the associations between sexual orientation and (a) rates of sexual violence and (b) substance use.

Results

Most women surveyed were heterosexual (64%), and 35% of all women reported unwanted sex. Sexual minority women (SMW) reported higher rates of sexual violence and substance use than heterosexual women. Sexual violence was more strongly associated with heavy alcohol use, but not with marijuana or cigarette use, for SMW than heterosexual women. Rates of sexual violence varied based on the intersection of sexual orientation and race/ethnicity. Although SMW were more likely to report sexual violence than heterosexual women, this association was weaker for Black/Latinx women than for non-Hispanic White women (aOR = 0.39, 95%CI [0.18, 0.82]). Race/ethnicity did not moderate the strength of associations between sexual violence and substance use.

Conclusions

SMW exhibit increased risk for sexual violence and substance use, and victimization was associated with heavy alcohol use. Few racial/ethnic differences emerged as a function of sexual orientation, so SMW are a group with unique needs around sexual violence experiences and substance use, regardless of race/ethnicity. Healthcare providers should be aware of the link between substance use and prior victimization when treating SMW.

A need for trauma informed care in sexually transmitted disease clinics

OBJECTIVE

This review examines trauma from violence as a risk factor for sexually transmitted diseases (STDs) among women attending STD clinics. The review also aims to suggest trauma informed care (TIC) integrated into STD clinics might more effectively address traumatic effects of violence linked to sexual risk behaviors among this population.

DESIGN AND SAMPLE

A systematic literature review was conducted to identify empirical studies examining the relationship between multiple forms of violence and sexual risk behaviors among women attending STD clinics.

RESULTS

All studies found high rates of violence including childhood sexual abuse, intimate partner violence, and/or community violence associated with high rates of sexual risk behaviors among women attending these settings. Researchers recommend screening for multiple forms of violence, interdisciplinary STD clinic services, and more trauma informed sexual risk reduction interventions to address multiple forms of violence found prevalent among this population.

CONCLUSION

Women attending STD clinics very often experience multiple forms of violence during their lifetime. TIC to address traumatic effects of violence might reduce sexual risk behaviors and sexually transmitted disease rates for improved health outcomes among this population.

A Brief Clinic-Based Intervention to Reduce Alcohol Misuse and Sexual Risk Behavior in Young Women: Results from an Exploratory Clinical Trial

This exploratory trial determined the feasibility, acceptability, and preliminary efficacy of a brief intervention (BI), supplemented with text messaging and a curated Web site, on alcohol use and sexual risk behavior among young women. Young women seeking care at a reproductive health clinic were screened for alcohol misuse and sexual risk behavior. Those who screened positive and who agreed to participate (N = 48; M = 22.67 years) were randomized to either (a) a brief in-person session during which personalized feedback regarding alcohol use and sexual risk taking was provided and discussed, or (b) a control condition. Feasibility was assessed by recruitment and retention rates. Acceptability was assessed with participant ratings of their intervention. Efficacy was measured using self-reported alcohol use and sexual behavior at baseline and during a 3-month follow-up. We supplemented the quantitative data with qualitative data from semi-structured interviews. Feasibility data indicated that 64% of eligible women agreed to participate, 74% of eligible women were enrolled, and 86% of enrolled women were retained through follow-up. Acceptability data showed that women who received the BI reported strong satisfaction with their intervention (M = 4.65 vs. 3.98 on a five-point scale) and also reported that text messaging was helpful (M = 4.73 on a seven-point scale) and acceptable (M = 5.27 on a seven-point scale). Qualitative data provided additional support for BI feasibility and acceptability. Efficacy data showed that women in both conditions reduced alcohol use and sexual risk behavior over time; women who received the BI reduced their maximum daily alcohol intake more than controls (BI from 7.68 to 4.82 standard drinks vs. control from 6.48 to 5.65; Wald χ² = 4.93, p < .05). Women in the BI reported fewer occasions of condomless sex (median = 2.50) than controls (median = 5.00) at the follow-up, but this difference was not statistically significant (OR = 0.61, 95% CI [0.32, 1.15]). A brief intervention, supplemented with text messaging and a Web site, that targeted alcohol use and sexual behavior was feasible and acceptable to young women and led to lower levels of alcohol misuse and sexual risk behavior.

The Need and Desire for Mental Health and Substance Use-Related Services Among Clients of Publicly Funded Sexually Transmitted Infection Clinics in Vancouver, Canada

CONTEXT

Sexually transmitted infections (STI) and mental health and substance use (MHSU) disorders all occur at elevated rates in sexual and gender minorities. These overlapping epidemics, or syndemics, are exacerbated by challenges these same populations face in accessing sexual/gender minority-affirming services. Many publicly funded STI clinics are a low barrier and provide sexual minority-competent care. These sites therefore may be uniquely situated to address clients' MHSU-related needs.

OBJECTIVE

We characterize the need and desire for MHSU services among STI clinic clients.

DESIGN, SETTING, PARTICIPANTS

We conducted a waiting room survey at 6 STI clinics in Metro Vancouver, Canada.

MAIN OUTCOME MEASURES

We calculated the proportion of clients with self-reported unmet MHSU needs in the previous 12 months and, among these clients, barriers to accessing MHSU services and desire for MHSU services within the STI clinic. We also examined social disparities in barriers to accessing MHSU services.

RESULTS

Among 1115 respondents-65% of whom were sexual minorities-39% reported a recent need for MHSU-related care, most frequently in relation to anxiety (29%), depression (26%), substance use (10%), or suicide ideation (7%). Seventy-two percent of this group had not yet talked to a provider about their concern. Common barriers included shame (26%) and inability to afford the service (24%). Eighty-three percent of clients with unmet MHSU needs indicated that they were comfortable discussing MHSU concerns with an STI clinic provider, and 94% expressed desire to receive MHSU assessments, referrals, or counseling in the STI clinic. Sexual and gender minorities and those attending a suburban clinic were more likely to report barriers to accessing MHSU services.

CONCLUSIONS

More than a quarter of STI clinic clients report unmet MHSU health care needs; moreover, these clients report high levels of comfort with and desire to discuss MHSU concerns with STI clinic providers. Sexually transmitted infections clinics are thus opportune sites for syndemic service integration.

From silos to buckets: a qualitative study of how sexual health clinics address their clients' mental health needs

OBJECTIVES

To describe the current constraints, facilitators, and future prospects for addressing mental health and substance use (MHSU) concerns within sexual health clinics in two cities in British Columbia, Canada.

METHODS

We conducted in-depth interviews with 22 providers (14 nurses, 3 physicians, 3 administrators, 2 other health professionals) from six sexual health clinics.

RESULTS

Providers consistently affirmed that MHSU-related concerns co-occur with sexual health concerns among clients presenting to sexual health clinics. Three factors constrained the providers' abilities to effectively address MHSU service needs: (1) clinic mandates or funding models (specific to sexually transmitted infections (STI)/HIV or reproductive health); (2) "siloing" (i.e., physical and administrative separation) of services; and (3) limited familiarity with MHSU service referral pathways. Mental health stigma was an additional provider-perceived barrier for sexual health clinic clients. The low barrier, "safe" nature of sexual health clinics, however, facilitated the ability of clients to open up about MHSU concerns, while the acquired experiences of sexual health nurses in counselling enabled clinicians to address clients' MHSU needs. In response to this context, participants described actionable solutions, specifically co-location of sexual health and MHSU services.

CONCLUSION

Sexual health clinicians in British Columbia generally affirm the results of previous quantitative and client-focused research showing high rates of MHSU-related needs among sexual health clinic clients. Providers prioritized specific short-term (referral-focused) and long-term (healthcare re-organization, co-location of sexual and MHSU services) solutions for improving access to MHSU services for those using sexual health services.

The condom purchase task: A hypothetical demand method for evaluating sexual health decision-making

Behavioral economic theory has proved useful for understanding the influence of delay and probability on sexual health decision-making. Demand is another principle at the intersection of microeconomics and psychology that has helped advance research relevant to health behaviors. The purpose of the present study was to develop and test a demand measure related to sexual health decision-making and the influence of sexually transmitted infection (STI) risk. Participants (N = 438) recruited using Amazon Mechanical Turk completed a commodity purchase task assessing hypothetical condom demand. Condom demand was evaluated at varied prices for use with hypothetical sexual partners that varied in STI risk. Demand was characterized by prototypic decreases in consumption with increases in cost. Higher partner STI risk was associated with greater intentions for condom-protected sex at no cost and smaller decreases in condom demand with increases in cost. Price sensitivity was also related to individual difference factors relevant to sexual health (e.g., alcohol use severity, lower STI knowledge). This study supports the utility of a condom purchase task for indexing condom valuation and capturing individual difference and contextual risk factors relevant to STI transmission. Future studies may leverage this methodology as a means to study sexual health decision-making.

Risk factors predictive of sexually transmitted infection diagnosis in young compared to older patients attending sexually transmitted diseases clinics

Young people aged less than 25 years bear the highest burden of sexually transmitted infections (STIs) in the United States. Here we sought to characterize patients aged 15–24 compared with patients ≥age 25 utilizing a database of first visits to two STI clinics in Baltimore, USA from 2011 to 2016. Acute STI (aSTI) was defined as gonorrhea (GC), trichomonas, or early syphilis (ES) in women and non-gonococcal urethritis, GC, Chlamydia (CT), and ES in men. Proportions were compared using the Chi square test and logistic regression was used to assess aSTI predictors in younger versus older groups, stratified by gender. Fifteen thousand four hundred and sixty-three first visits for patients <25 and 25,203 for patients ≥25 were analyzed. Participants <25 were more likely to be Black and less likely to self-identify as straight than those ≥25. While younger patients had more partners, they were less likely to report risk behaviors such as ‘Never’ using condoms, cocaine use, and sex with alcohol than older patients. Predictors of aSTI risk differed both by age and gender. STI prevention messages should be tailored, and access to screening should be optimized for young men and women, in order to address rising STI rates in this population.

Alcohol Use and Sexual Risk Behavior in Young Women: A Qualitative Study

Alcohol use and sexual behavior co-occur frequently in young women, increasing risk for HIV and other sexually transmitted infections. To inform preventive interventions, we used qualitative methods to better understand how women think about the contribution of alcohol use to sexual risk-taking. Young women (N = 25; M = 22.8 years; 64% White) were recruited from a community-based reproductive health clinic to attend focus groups; a semi-structured agenda was used to investigate both a priori explanatory mechanisms as well as participant-driven explanations for the alcohol-sex association. Women reported that alcohol reduced their social anxiety, helped them to feel outgoing and confident, and lowered inhibitions and other barriers to sexual encounters (consistent with alcohol expectancies). During drinking events, women described being less concerned with risks, less discriminating regarding sexual partners, and less likely to insist on safer sex practices (consistent with alcohol myopia). These empirical findings support previous theory-based guidance for tailoring preventive programs for alcohol use and sexual risk reduction for young women.

Sexual risk reduction interventions for patients attending sexual health clinics: a mixed-methods feasibility study

BACKGROUND

Sexually transmitted infections (STIs) continue to represent a major public health challenge. There is evidence that behavioural interventions to reduce risky sexual behaviours can reduce STI rates in patients attending sexual health (SH) services. However, it is not known if these interventions are effective when implemented at scale in SH settings in England.

OBJECTIVES

The study (Santé) had two main objectives - (1) to develop and pilot a package of evidence-based sexual risk reduction interventions that can be delivered through SH services and (2) to assess the feasibility of conducting a randomised controlled trial (RCT) to determine effectiveness against usual care.

DESIGN

The project was a multistage, mixed-methods study, with developmental and pilot RCT phases. Preparatory work included a systematic review, an analysis of national surveillance data, the development of a triage algorithm, and interviews and surveys with SH staff and patients to identify, select and adapt interventions. A pilot cluster RCT was planned for eight SH clinics; the intervention would be offered in four clinics, with qualitative and process evaluation to assess feasibility and acceptability. Four clinics acted as controls; in all clinics, participants would be consented to a 6-week follow-up STI screen.

SETTING

SH clinics in England.

PARTICIPANTS

Young people (aged 16-25 years), and men who have sex with men.

INTERVENTION

A three-part intervention package - (1) a triage tool to score patients as being at high or low risk of STI using routine data, (2) a study-designed web page with tailored SH information for all patients, regardless of risk and (3) a brief one-to-one session based on motivational interviewing for high-risk patients.

MAIN OUTCOME MEASURES

The three outcomes were (1) the acceptability of the intervention to patients and SH providers, (2) the feasibility of delivering the interventions within existing resources and (3) the feasibility of obtaining follow-up data on STI diagnoses (primary outcome in a full trial).

RESULTS

We identified 33 relevant trials from the systematic review, including videos, peer support, digital and brief one-to-one sessions. Patients and SH providers showed preferences for one-to-one and digital interventions, and providers indicated that these intervention types could feasibly be implemented in their settings. There were no appropriate digital interventions that could be adapted in time for the pilot; therefore, we created a placeholder for the purposes of the pilot. The intervention package was piloted in two SH settings, rather than the planned four. Several barriers were found to intervention implementation, including a lack of trained staff time and clinic space. The intervention package was theoretically acceptable, but we observed poor engagement. We recruited patients from six clinics for the follow-up, rather than eight. The completion rate for follow-up was lower than anticipated (16% vs. 46%).

LIMITATIONS

Fewer clinics were included in the pilot than planned, limiting the ability to make strong conclusions on the feasibility of the RCT.

CONCLUSION

We were unable to conclude whether or not a definitive RCT would be feasible because of challenges in implementation of a pilot, but have laid the groundwork for future research in the area.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN16738765.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 12. See the NIHR Journals Library website for further project information.

Pilot Studies Examining Feasibility of Substance Use Disorder Screening and Treatment Linkage at Urban Sexually Transmitted Disease Clinics

BACKGROUND

Sexually transmitted disease (STD) clinics provide critical public health services for screening and treatment of sexually transmitted infections throughout the United States. These settings serve high-risk populations, often on a walk-in basis, and may be promising venues for integrating substance use disorder (SUD) services.

METHODS

We report findings from 2 pilot studies conducted at Baltimore City Health Department's STD clinics. The screening study characterized rates of SUDs among STD clinic patients. Patients waiting for services completed a diagnostic interview mapping to Diagnostic and Statistical Manual of Mental Disorders, 5th Edition SUD criteria (n = 100). The Treatment Linkage Feasibility study examined the feasibility of linking STD clinic patients with opioid and/or cocaine use disorders to SUD treatment in the community (n = 21), using SUD-focused Patient Navigation services for 1 month after the STD clinic visit. Assessments were conducted at baseline and 1-month follow-up.

RESULTS

In the screening study, the majority of STD clinic patients met diagnostic criteria for alcohol and/or drug SUD (57%). Substance-specific SUD rates among patients were 35% for alcohol, 31% for cannabis, 11% for opioids, and 8% for stimulants (cocaine/amphetamines). In the Treatment Linkage Feasibility study, 57% (12/21) of participants attended at least 1 SUD service, and 38% (8/21) were actively enrolled in SUD treatment by 1-month follow-up. The sample reported significant reductions in past 30-day cocaine use from baseline to follow-up (P = 0.01).

CONCLUSIONS

SUD rates are high among STD clinic patients. STD clinics are viable settings for initiating SUD treatment linkage services. Larger-scale research on integrating SUD services in these settings is needed.

Designing a brief behaviour change intervention to reduce sexually transmitted infections: a discrete choice experiment

To understand whether people attending sexual health (SH) clinics are willing to participate in a brief behavioural change intervention (BBCI) to reduce the likelihood of future sexually transmitted infections (STIs) and to understand their preferences for different service designs, we conducted a discrete choice experiment (DCE) with young heterosexual adults (aged 16-25 years), and men who have sex with men (MSM) aged 16 or above, attending SH clinics in England. Data from 368 participants showed that people particularly valued BBCIs that involved talking (OR 1.45; 95%CI 1.35, 1.57 compared with an 'email or text'-based BBCIs), preferably with a health care professional rather than a peer. Findings also showed that 26% of respondents preferred 'email/texts' to all other options; the remaining 14% preferred not to participate in any of the offered BBCIs. These results suggest that most people attending SH clinics in England are likely to participate in a BBCI if offered, but the type/format of the BBCI is likely to be the single important determinant of uptake rather than characteristics such as the length and the number of sessions. Moreover, participants generally favoured 'talking'-based options rather than digital alternatives, which are likely to require the most resources to implement.

Factors associated with tobacco, alcohol, and other drug use among youth living in West Central Mexico

AIM

To determine the prevalence of drug and substance abuse among high school students in Jalisco and its association with the severity of health, behavior and psychosocial problems in order to provide evidence for possible prevention and treatment needs.

METHODS

A multi-stage random sample of Jalisco high school students was given a paper-and-pencil survey based upon an adapted version of the drug use screening inventory (DUSI) (n = 24699; n = 2832). The DUSI showed adequate psychometric characteristics in this population. The statistical analyses accommodated the complex survey design with attention to unequal probability of selection and clustering of participants within schools and regions.

RESULTS

An estimated 44% of the students had smoked tobacco, one in five students was a current smoker, and one in four students used to smoke but had not smoked for one year or more. By contrast, 6.8% of the students reported having used marijuana, cocaine, or both. Behavioral problems, deviant peer affiliation, and troubled families were independently associated with drug use. One in two students who used tobacco or alcohol had used these drugs in the past year (46% and 54%, respectively), and one in four students who used marijuana or cocaine in their lifetime had used those drugs in the past year (28% in both cases).

CONCLUSION

The rates of cocaine use as well as the proportion of current users were higher than expected among high school students and indicate changing patterns of drug use in Mexico. These results corroborate that the general trend of drug use by youth in Mexico is increasing. Results from this study help us better understand the needs of at-risk youth and the need for new treatment and prevention strategies.

Using Integrative Data Analysis to Examine Changes in Alcohol Use and Changes in Sexual Risk Behavior Across Four Samples of STI Clinic Patients

BACKGROUND

Patients in sexually transmitted infection (STI) clinics report high levels of alcohol use, which are associated with risky sexual behavior. However, no studies have examined how changes in alcohol use relate to changes in sexual risk behavior.

PURPOSE

We used parallel process latent growth modeling to explore how changes in alcohol use related to changes in sexual behavior across four samples of clinic patients.

METHODS

Patients participating in HIV prevention trials from urban clinics in the Northeastern and Midwestern USA (N = 3761, 59 % male, 72 % Black) completed measures at 3-month intervals over 9-12 months. Integrative data analysis was used to create composite measures of alcohol use across samples. Sexual risk measures were counts of partners and unprotected sex acts. Parallel process models tested whether alcohol use changes were correlated with changes in the number of partners and unprotected sex.

RESULTS

Growth models with good fit showed decreases that slowed over time in sexual risk behaviors and alcohol use. Parallel process models showed positive correlations between levels of (rs = 0.17-0.40, ps < 0.001) and changes in (rs = 0.21-0.80, ps < 0.05) alcohol use and number of sexual partners across studies. There were strong associations between levels of (rs = 0.25-0.43, ps < 0.001) and changes in (rs = 0.24-0.57, ps < 0.01) alcohol use and unprotected sex in one study recruiting hazardous drinkers.

CONCLUSIONS

Across four samples of clinic patients, reductions in alcohol use were associated with reductions in the number of sexual partners. HIV prevention interventions may be strengthened by addressing alcohol use.

Interest in using mobile technology to help self-manage alcohol use among persons living with the human immunodeficiency virus: A Florida Cohort cross-sectional study

BACKGROUND

Alcohol consumption at hazardous levels is more prevalent and associated with poor health outcomes among persons living with the human immunodeficiency virus (HIV; PLWH). Although PLWH are receptive to using technology to manage health issues, it is unknown whether a cell phone app to self-manage alcohol use would be acceptable among PLWH who drink. The objectives of this study were to determine factors associated with interest in an app to self-manage drinking and to identify differences in baseline mobile technology use among PLWH by drinking level.

METHODS

The study population included 757 PLWH recruited from 2014 to 2016 into the Florida Cohort, an ongoing cohort study investigating the utilization of health services and HIV care outcomes among PLWH. Participants completed a questionnaire examining demographics, substance use, mobile technology use, and other health behaviors. Multivariable logistic regression was used to identify factors significantly associated with interest in an app to self-manage drinking. We also determined whether mobile technology use varied by drinking level.

RESULTS

Of the sample, 40% of persons who drink at hazardous levels, 34% of persons who drink at nonhazardous levels, and 19% of persons who do not drink were interested in a self-management app for alcohol use. Multivariable logistic regression analysis indicated that nonhazardous drinking (adjusted odds ratio [AOR] = 1.78; confidence interval [CI 95%]: 1.10-2.88) and hazardous drinking (AOR = 2.58; CI: 1.60-4.16) were associated with interest, controlling for age, gender, education, and drug use. Regarding mobile technology use, most of the sample reported smartphone ownership (56%), text messaging (89%), and at least one cell phone app (69%).

CONCLUSIONS

Regardless of drinking level, overall mobile technology use among PLWH was moderate, whereas PLWH who consumed alcohol expressed greater interest in a cell phone app to self-manage alcohol use. This indicates that many PLWH who drink would be interested in and prepared for a mobile technology-based intervention to reduce alcohol consumption.

Prevalence of Alcohol Use, Sexual Risk Behavior, and HIV Among Russians in High-Risk Settings: a Systematic Review and Meta-Analysis

PURPOSE

The purpose of this study was to examine the (a) prevalence of and (b) association between alcohol, risky sex, and HIV among Russians at risk for primary or secondary HIV transmission.

METHOD

Electronic databases were searched to locate studies that sampled Russians, assessed alcohol use, and included either a behavioral measure of risk or a biological measure of HIV. Weighted mean (logit) effect sizes were calculated using random-effects assumptions. Moderator analyses were conducted using meta-regression.

RESULTS

Studies (19) sampled 12,916 Russians (M age = 29; 36 % women). Participants were recruited from clinical (52 %; e.g., sexually transmitted infection (STI) clinic, drug treatment), other high-risk community settings (32 %; e.g., sexual/drug networks), or both (16 %). Findings indicate that a substantial proportion of the participants used alcohol (77 %; 55 % heavy drinking). One half of participants reported using condoms (52 %), but only 29 % used condoms consistently. Most participants reported drinking before sex (64 %). Of the studies testing for HIV, 10 % of participants tested positive. Meta-regression analyses indicated that hazardous/harmful alcohol use was associated with increased risky behaviors (i.e., multiple partners, inconsistent condom use).

CONCLUSION

These findings support the need for and potential benefit of addressing alcohol use in HIV prevention programming in Russia.

Testing a Brief Substance Misuse Preventive Intervention for Parents of Pre-Adolescents: Feasibility, Acceptability, Preliminary Efficacy

Evidence-based interventions to reduce substance misuse among adolescents are resource and time intensive. We conducted a pilot RCT to evaluate a novel, adaptable, and resource-efficient substance misuse preventive intervention for parents/guardians, focusing on talking with children about substance use and on eating family meals. We randomized 70 parents of children in third-through-sixth grades within a large, urban public school system in New England to the intervention or control condition. Over a six-month follow-up period, we assessed feasibility and acceptability of the intervention and examined frequency of parent-child conversations about alcohol, marijuana, and other drugs, and frequency and duration of family meals. A total of 29 parents were assigned to the intervention and 35 to the control condition. The intervention was found to be feasible and acceptable to participants as evidenced by high recruitment and retention rates and positive feedback from qualitative exit interviews. At three- and six-month follow up, 64.3% and 44.5% of parents in the intervention condition were talking "a lot" to their children about alcohol, compared to 8.7% and 8.7% of the parents in the control condition, respectively (p<0.01 and p=0.03). Patterns in frequency and duration of family meals between the two conditions were not significantly different over time. In conclusion, a higher percentage of parents randomized to the intervention condition spoke with their children about alcohol, marijuana, and other drugs, but the frequency and duration of meals was not impacted. Further testing of the brief intervention with a larger sample to assess efficacy is warranted.

Substance use and STI acquisition: Secondary analysis from the AWARE study

OBJECTIVES

Sexually transmitted infections (STIs) are significant public health and financial burdens in the United States. This manuscript examines the relationship between substance use and prevalent and incident STIs in HIV-negative adult patients at STI clinics.

METHODS

A secondary analysis of Project AWARE was performed based on 5012 patients from 9 STI clinics. STIs were assessed by laboratory assay and substance use by self-report. Patterns of substance use were assessed using latent class analysis. The relationship of latent class to STI rates was investigated using Poisson regression by population groups at high risk for STIs defined by participant's and partner's gender.

RESULTS

Drug use patterns differed by risk group and substance use was related to STI rates with the relationships varying by risk behavior group. Substance use treatment participation was associated with increased STI rates.

CONCLUSIONS

Substance use focused interventions may be useful in STI clinics to reduce morbidity associated with substance use. Conversely, gender-specific sexual health interventions may be useful in substance use treatment.

First Evaluation of a Contingency Management Intervention Addressing Adolescent Substance Use and Sexual Risk Behaviors: Risk Reduction Therapy for Adolescents

There is a need for interventions that comprehensively address youth substance use disorders (SUD) and sexual risk behaviors. Risk Reduction Therapy for Adolescents (RRTA) adapts a validated family-focused intervention for youth SUD to include sexual risk reduction components in a single intervention. In this first evaluation of RRTA, drug court involved youth were randomly assigned to RRTA (N=45) or usual services (US; N=60) and followed through 12-months post-baseline. RRTA included weekly cognitive behavior therapy and behavior management training and contingency-contracting with a point earning system managed by caregivers targeting drug use and sexual risk antecedents. Longitudinal models estimated within-group change and between-group differences through 6- and 12-month follow-up on outcomes for substance use, sexual risk behaviors, and protective HIV behaviors. Robust effects of the intervention were not detected under conditions of the study that included potent background interventions by the juvenile drug court. Considerations about future development and testing of sexual risk reduction therapy for youth are discussed, including the potential role of contingency management in future interventions.

Alcohol Use Predicts Number of Sexual Partners for Female but not Male STI Clinic Patients

This study tested the hypothesis that greater alcohol involvement will predict number of sexual partners to a greater extent for women than for men, and that the hypothesized sex-specific, alcohol-sexual partner associations will hold when controlling for alternative sex-linked explanations (i.e., depression and drug use). We recruited 508 patients (46 % female, 67 % African American) from a public sexually transmitted infections (STI) clinic. Participants reported number of sexual partners, drinks per week, maximum drinks per day, frequency of heavy drinking; they also completed the AUDIT-C and a measure of alcohol problems. As expected, men reported more drinking and sexual partners. Also as expected, the association between alcohol use and number of partners was significant for women but not for men, and these associations were not explained by drug use or depression. A comprehensive prevention strategy for women attending STI clinics might include alcohol use reduction.

Delayed Ego Strength Development in Opioid Dependent Adolescents and Young Adults

Objective. To evaluate ego strengths, in the context of Erikson's framework, among adolescents and young adults diagnosed with opioid dependence as compared to non-drug using youth. Methods. Opioid dependent (n = 51) and non-drug using control (n = 31) youth completed the self-administered Psychosocial Inventory of Ego Strengths (PIES). The PIES assesses development in the framework of Erikson's ego strength stages. Multivariate linear regression modeling assessed the independent association of the primary covariate (opioid dependent versus control) as well as potential confounding variables (e.g., psychiatric comorbidities, intelligence) with total PIES score. Results. Mean total PIES score was significantly lower in opioid dependent youth (231.65 ± 30.39 opioid dependent versus 270.67 ± 30.06 control; p < 0.01). Evaluation of the PIES subscores found significant (p < 0.05) delays in all ego strength areas (hope, will, purpose, competence, fidelity, love, care, and wisdom). When adjusting for potential confounders, opioid dependence remained a significant (p < 0.001) independent predictor of total PIES score. Conclusion. Adolescents with opioid dependence demonstrated significant delays in ego strength development. A treatment approach acknowledging this delay may be needed in the counseling and treatment of adolescents with opioid dependence.

Spanish adaptation and validation of the Barratt Impulsiveness Scale for early adolescents (BIS-11-A)

Impulsivity has been associated with several psychiatric disorders such as substance abuse. The Barratt Impulsiveness Scale (BIS-11) is one of the most commonly administered self-reports for the assessment of impulsiveness in both research and clinical settings. There is a version for adolescents called BIS-11-A, which has not been yet properly adapted to Spanish population. The goal of this study is to offer an alternative and more adequate Spanish version of the BIS-1-A, as well as to assess its psychometric properties including factor structure, reliability and predictive validity regarding substance use (last month alcohol, tobacco and cannabis use, presence of last month intoxication, binge drinking and problem drinking). The BIS-11-A and items from the European School Survey Project on Alcohol and other Drugs (ESPAD) were applied to1,183 students (aged 12-14) at 16 Spanish secondary schools. The BIS-11-A showed a bidimensional factor structure, high reliability (Cronbach's alpha = .87) and good capacity for identifying substance use, binge drinking and problem drinking (sensitivity = 67.3-75%; specificity = 83.4-85.4%). The BIS-11-A Spanish version is a reliable and valid instrument for be used among early adolescents.

Risky Sexual Behavior and Substance Use among Adolescents: A Meta-analysis

This study presents the results of a meta-analysis of the association between substance use and risky sexual behavior among adolescents. 87 studies fit the inclusion criteria, containing a total of 104 independent effect sizes that incorporated more than 120,000 participants. The overall effect size for the relationship between substance use and risky sexual behavior was in the small to moderate range (r = .22, CI = .18, .26). Further analyses indicated that the effect sizes did not substantially vary across the type of substance use, but did substantially vary across the type of risky sexual behavior being assessed. Specifically, mean effect sizes were smallest for studies examining unprotected sex (r = .15, CI = .10, .20), followed by studies examining number of sexual partners (r = .25, CI = .21, .30), those examining composite measures of risky sexual behavior (r = .38, CI = .27, .48), and those examining sex with an intravenous drug user (r = .53, CI = .45, .60). Furthermore, our results revealed that the relationship between drug use and risky sexual behavior is moderated by several variables, including sex, ethnicity, sexuality, age, sample type, and level of measurement. Implications and future directions are discussed.

Differences in sexual risk behaviors between lower and higher frequency alcohol-using African-American adolescent females

BACKGROUND

To examine differences between lower and higher frequency alcohol users in sexual behaviors and psychosocial correlates of risk for HIV among young African-American females.

METHODS

Data were collected from sexually active African-American females aged 15-20 years, seeking services at a STD clinic in Atlanta, GA, to assess sexual behavior, correlates of risk, and a non-disease biological marker of unprotected vaginal sex.

RESULTS

Number of drinking occasions was significantly related to three of four psychosocial correlates and with all self-reporting sexual behavior measures. Also, heavier drinking per occasion was associated with the presence of semen in vaginal fluid.

CONCLUSION

Non-abuse levels of drinking were related to increased sexual risk-taking in this sample of young African- American females. Incorporating messages about the intersection of alcohol use and sexual decision making into HIV/STD prevention programs would strengthen STD prevention messaging in this vulnerable population.

Problematic recreational drug use: is there a role for outpatient sexual health clinics in identifying those not already engaged with treatment services?

Background There is an association between recreational drug use, high-risk sexual activity and sexually transmissible infections. Studies have shown a higher prevalence of drug use in those accessing sexual health services; however, there are minimal data on the proportion with problematic recreational drug use. We aimed to understand whether sexual health clinics could identify problematic drug and alcohol use as a novel referral pathway into treatment services. Methods: Males attending two sexual health clinics in London completed questionnaires. Data were collected on demographics; gender of sexual partner; use of alcohol and recreational drugs; if they felt they had problematic use of drugs, alcohol or both; and if they had sought help for their problematic use. Results: In total, 867 males completed the questionnaire; 387 (44.7%) were men who have sex with men (MSM). MSM had significantly higher lifetime use of any drug compared with non-MSM (80.6% vs. 62.5%; P < 0.0001). Thirty-five (4.7%) self-identified problematic drug or alcohol use, with no difference between MSM and non-MSM (6.3% vs. 3.5%; P = 0.08). Of those with problematic drug or alcohol use, 20 were currently or had been engaged with a treatment service and 15 had never engaged with treatment services. MSM were more likely to have ever sought help for drug or alcohol problems compared with non-MSM (P = 0.003). Conclusions: Some individuals attending sexual health clinics with problematic drug use have not engaged with treatment services. It is therefore appropriate to develop screening tools for sexual health clinics to identify these individuals and novel referral pathways to engage them in treatment services.

Gambling and sexual behaviors in African-American adolescents

OBJECTIVES

Late adolescence represents a developmental risk period when many youth become involved in multiple forms of high-risk behaviors with adverse consequences. This study assessed the degree to which two such behaviors, adolescent sexual behaviors and gambling, were associated in a community-based sample with a large African-American presence.

STUDY DESIGN

Data are derived from a cohort study. This study focuses on 427 African-American participants with complete information on gambling and sexual behaviors by age 18 (72% of original cohort). Gambling involvement and related problems were based on responses to the South Oaks Gambling Screen - Revised for Adolescents. Several questions assessed sexual behaviors, including age of initiation. Multivariable logistic regression models adjusted for demographics, intervention status, impulsivity, depressive and anxiety symptoms, and alcohol and illegal drug use.

RESULTS

Almost half of the sample (49%, n=211) had gambled at least once before age 18. More gamblers than non-gamblers had initiated sexual intercourse by age 18 (aOR: 2.29 [1.16, 4.52]). Among those who had initiated sexual activity, more gamblers than non-gamblers with high impulsivity levels at age 13 (vs. low impulsivity levels) had become pregnant or had impregnated someone. Among those who had initiated sexual activity by age 18, more male gamblers had impregnated someone by age 18 as compared to female gamblers becoming pregnant.

CONCLUSIONS

Gambling and sexual behaviors often co-occur among adolescents. Such findings prompt the need for the inclusion of gambling, an often overlooked risky behavior, in behavioral prevention/intervention programs targeting adolescents.

Risk Reduction Therapy for Adolescents: Targeting Substance Use and HIV/STI-Risk Behaviors

This paper describes a family-based intervention for addressing both substance use and unprotected sexual behavior in adolescents presenting for outpatient substance use treatment. The intervention combines contingency management (CM) for adolescent substance use, which is a behavioral intervention modeled on the Community Reinforcement Approach, with a sexual risk reduction protocol that mirrors aspects of the CM model. As a family-based intervention, caregivers attend every session and actively collaborate with the therapist to address their youth's behavior problems. The treatment is criterion-based with treatment duration determined by the youth's achievement of reduced substance use and unprotected sexual behavior goals. A case study describes the implementation of this treatment with an adolescent presenting a history of polysubstance use and unprotected sexual intercourse. Following the adolescent and caregiver's participation in weekly sessions, the adolescent demonstrated improvements in substance use, unprotected sexual behavior, and other behavior problems. Clinical summary data from two outpatient clinics reveal similar positive outcomes for youth receiving the intervention. This paper illustrates the potential utility of an integrated treatment approach targeting substance use and unprotected sexual behavior in an adolescent population.

Utilization of information and communication technology (ICT) among sexually transmitted disease clinics attendees with coexisting drinking problems

BACKGROUND

Alcohol misuse remains a major risk factor for contracting sexually transmitted diseases (STDs) not typically addressed in STD clinic settings. Information and communication technology (ICT) can offer new avenues to deliver evidence-based screening and treatment for problematic drinking, however, few data exists regarding the utilization of ICT among STD clinic attendees with coexisting drinking problems. The objectives of this study are to identify STD clinics attendees with hazardous drinking, to examine socio-demographic factors associated with ICT use, and to explore individuals' interests in engaging in ICT-based health interventions.

METHODS

Cross-sectional questionnaires examining alcohol consumption and ICT use were administered to 396 persons attending two non-urban STD clinics. Descriptive statistics for ICT use were calculated for both hazardous drinkers and the entire sample. Multivariable logistic regression models among hazardous drinkers identified factors significantly associated with use of each kind of ICT.

RESULTS

The mean age of the 396 participants was 25 years, 66% were females and 60% were African-Americans. One third of the sample met the criteria of hazardous drinking. ICT use in hazardous drinkers included 94% reporting having internet access at least monthly, 82% reporting having an email account, 85% reporting currently owning a cell phone, and 91% reporting use of any cell phone application. More than two thirds (73%) of hazardous drinkers were willing to play health-related video games during clinic waiting time, slightly higher than the entire sample (69%). Multivariable analyses indicated that younger age were significantly related to monthly internet use, and multifunction cell phone use, while being males and younger age were significantly associated with monthly video game playing.

CONCLUSIONS

Our study demonstrates commonality of ICT use among STD clinic attendees with hazardous drinking, indicating the viability of using ICT to assist screening and behavioural intervention for alcohol misuse in STD clinic settings. Future research is needed to demonstrate the effectiveness of ICT-based health behavioural interventions in the STD clinic settings or other venues that serve populations at high risk for substance abuse, HIV or other STDs.

A novel integration effort to reduce the risk for alcohol-exposed pregnancy among women attending urban STD clinics

Alcohol-exposed pregnancy (AEP) is a significant public health problem in the United States. Sexually transmitted disease (STD) clinics serve female clients with a high prevalence of heavy alcohol consumption coupled with ineffective contraceptive use. Project CHOICES (Changing High-Risk AlcOhol Use and Increasing Contraception Effectiveness) is an evidence-based, brief intervention to lower risk of AEP by targeting alcohol and contraceptive behaviors through motivational interviewing and individualized feedback. We describe our experience integrating and implementing CHOICES in STD clinics. This endeavor aligns with CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention's program collaboration and service integration strategic priority to strengthen collaborative work across disease areas and integrate services provided by related programs at the client level.

The relationship between substance use and sexual health among African-American female adolescents with a history of seeking mental health services

BACKGROUND

This study examined relationships between substance use patterns and problems and sexual health outcomes among low-income, urban, African-American female adolescents with a history of seeking mental health services.

METHODS

Participants were recruited from outpatient mental health clinics serving urban, primarily low-income youth and families in Chicago, Illinois, as part of a 2-year, longitudinal investigation of HIV risk behavior during which they completed interviews every 6 months (five time points). Girls who completed at least one follow-up interview were invited to participate in a sixth wave of assessment to assess trauma exposure, substance use problems, and sexual risk. The current study (n = 177) examined the association between sexual risk behavior and substance use problems reported at the most recent interview (ages 14-22) and substance use patterns and sexually transmitted infections (STI) reported at all six times points. Multiple regression examined the combined and unique effects of different patterns of substance use and substance use problems as correlates of sexual risk behavior and STIs.

FINDINGS

Substance use problems were associated with increased sexual risk behavior and increased likelihood of experiencing STIs. Substance use patterns were associated with sexual risk behavior.

CONCLUSIONS

Results suggest that specific patterns of substance use and substance use problems are important to address in sexual health promotion among low-income, urban, African-American girls with a history of seeking mental health services. Understanding the nuances of these relationships is important in informing how to best serve this vulnerable group of adolescents who experience significant sexual risk and mental health care disparities.

The relationships of sexual identity, hazardous drinking, and drinking expectancies with risky sexual behaviors in a community sample of lesbian and bisexual women

This study examined the influence of demographic characteristics, sexual identity, hazardous drinking, and sexuality/intimacy enhancement alcohol expectancies on rates of risky sexual behaviors in a community sample of women who self-identified as lesbian, mostly lesbian, and bisexual (N = 349). Structured interview data were collected as part of a larger longitudinal study of sexual minority women's health, the Chicago Health and Life Experiences of Women study. We used structural equation modeling, controlling for demographic characteristics, to evaluate the influence of sexual identity, hazardous drinking, and alcohol-related sexuality/intimacy enhancement expectancies on sexual risk behaviors. Controlling for demographic characteristics and for sexual identity, higher levels of both hazardous drinking and sexuality/intimacy enhancement alcohol expectancies were associated with higher sexual risk scores. The final model predicted 36% of the variance in risky sexual behavior scores. Our findings regarding the central role of alcohol use and sexuality/intimacy enhancement expectancies in sexual risk behaviors among sexual minority women are consistent with previous research focusing on predominantly heterosexual women. Future efforts at sexual risk reduction in sexual minority women will need to address the influences of alcohol use and drinking-related expectancies on sexual behaviors and decision making.

Optimizing the scientific yield from a randomized controlled trial (RCT): evaluating two behavioral interventions and assessment reactivity with a single trial

Randomized controlled trials (RCTs) remain the gold standard for evaluating intervention efficacy but are often costly. To optimize their scientific yield, RCTs can be designed to investigate multiple research questions. This paper describes an RCT that used a modified Solomon four-group design to simultaneously evaluate two, theoretically-guided, health promotion interventions as well as assessment reactivity. Recruited participants (N = 1010; 56% male; 69% African American) were randomly assigned to one of four conditions formed by crossing two intervention conditions (i.e., general health promotion vs. sexual risk reduction intervention) with two assessment conditions (i.e., general health vs. sexual health survey). After completing their assigned baseline assessment, participants received the assigned intervention, and returned for follow-ups at 3, 6, 9, and 12 months. In this report, we summarize baseline data, which show high levels of sexual risk behavior; alcohol, marijuana, and tobacco use; and fast food consumption. Sexual risk behaviors and substance use were correlated. Participants reported high satisfaction with both interventions but ratings for the sexual risk reduction intervention were higher. Planned follow-up sessions, and subsequent analyses, will assess changes in health behaviors including sexual risk behaviors. This study design demonstrates one way to optimize the scientific yield of an RCT.

Delay in Seeking Care for Sexually Transmitted Diseases in Young Men and Women Attending a Public STD Clinic

BACKGROUND

Delay in seeking care for sexually transmitted diseases (STDs) has adverse consequences for both the individual and population. We sought to identify factors associated with delay in seeking care for STDs.

METHODS

Subjects included 300 young men and women (aged 15-24) attending an urban STD clinic for a new STD-related problem due to symptoms or referral for an STD screening. Subjects completed a structured interview that evaluated STD history, attitudes and beliefs about STDs, depression, substance use, and other factors possibly associated with delay. Delay was defined as waiting > 7 days to seek and obtain care for STDs.

RESULTS

Nearly one-third of participants delayed seeking care for > 7 days. Significant predictors for delay included self-referral for symptoms as the reason for visit (OR 5.3, 95% CI: 2.58 - 10.98), and the beliefs "my partner would blame me if I had an STD" (OR 2.44, 95% CI: 1.30 - 4.60) and "it's hard to find time to get checked for STDs" (OR 3.62, 95% CI: 1.95 - 6.69), after adjusting for age, race, sex, and other factors. Agreeing with the statement "would use a STD test at home if one were available" was associated with a decrease in delay (OR 0.24, 95% CI: 0.09 - 0.60).

CONCLUSIONS

Many young persons delay seeking care for STDs for a number of reasons. Strategies to improve STD care-seeking include encouragement of symptomatic persons to seek medical care more rapidly, reduction of social stigmas, and improved access to testing options.

Factors associated with risky sexual practices among female sex workers in Karnataka, India

Introduction

The objectives of this study are to develop a summary measure of risky sexual practice and examine the factors associated with this among female sex workers (FSWs) in Karnataka, India.

Materials and Methods

Data were drawn from special behavioral surveys (SBS) conducted in 2007 among 577 FSWs in two districts of Karnataka, India: Belgaum and Bangalore. FSWs were recruited using the two-stage probability sampling design. FSWs' sexual practice was considered risky if they reported inconsistent condom use with any sexual partner and reported experience of one of the following vulnerabilities to HIV risk: anal sex, alcohol consumption prior to sex and concurrent sexual relationships.

Results

About 51% of FSWs had engaged in risky sexual practice. The odds of engaging in risky sex were higher among FSWs who were older (35+ years) than younger (18–25 years) (58% vs. 45%, Adjusted Odds Ratio (AOR): 2.0, 95% confidence interval (CI): 1.2–3.4), who were currently married than never married (61% vs. 51%, AOR: 4.8, 95% CI: 2.5–9.3), who were in sex work for 10+ years than those who were in sex work for less than five years (66% vs. 39%, AOR: 2.6, 95% CI: 1.6–4.2), and who had sex with 3+ clients/day than those who had sex with fewer clients (67% vs. 38%, AOR: 3.7, 95% CI:2.5–5.5).

Conclusion

FSWs who are older, currently married, practicing sex work for longer duration and with higher clientele were more likely to engage in risky sexual practices. HIV prevention programs should develop strategies to reach these most-at risk group of FSWs to optimize the effectiveness of such programs.

Anal sex and associated HIV-related sexual risk factors among female sex workers in Andhra Pradesh, India

BACKGROUND

This study aims to understand the correlates of anal sex practices among female sex workers (FSWs) and examine the association of anal sex with HIV-related sexual risk factors in Andhra Pradesh, India.

METHODS

A cross-sectional behavioural survey was conducted in 2011 among 795 FSWs aged 18 years or older. Probability-based cluster sampling was used to select respondents from sex work hotspots.

RESULTS

One-quarter (23%) of FSWs had practiced anal sex in the last year. The odds of practicing anal sex were higher among FSWs aged 35 years or more than in those aged less than 25 years (adjusted odds ratio (AOR): 2.05, P<0.05), in those formerly married compared to those currently married (AOR: 1.88, P<0.01), in those having an income only from sex work compared to those having additional sources of income (AOR: 1.54, P<0.05), those reporting heavy alcohol consumption compared to those who did not (AOR: 2.80, P<0.01) and those who experienced violence compared to those who had not (AOR: 2.80, P<0.01). FSWs practicing anal sex were more likely to experience sexually transmissible infection (STI) related symptoms than those practicing only vaginal sex. There was no association between anal sex practice and condom use.

CONCLUSIONS

Anal sex is associated with STI symptoms, a factor for HIV risk. HIV intervention programmes need to educate FSWs about the risks associated with anal sex.

The association between alcohol use and sexual risk behaviors among African American women across three developmental periods: a review

BACKGROUND

African American women experience increased rates of sexually transmitted diseases and HIV. The use of alcohol may increase sexual risk behaviors among this population.

PURPOSE

This paper provides a review and critique of the literature examining the association between alcohol use and sexual risk behaviors among African American females including a: (a) synthesis of research findings from adolescent, college-aged/early adulthood, and adult samples; (b) methodological critique of the literature; and (c) guidance for future research.

METHODS

We reviewed 32 studies examining the association between alcohol use and sexual risk behaviors among African American females across developmental periods.

RESULTS

Similar to previous association studies, results suggest that increased use of alcohol is associated with increased sexual risk practices among African American females. Further, even non-abuse levels of drinking among African American females, at all ages, were related to increased sexual risk-taking.

CONCLUSIONS

Future studies should seek to recruit samples that more fully reflect the diversity of African American women's experiences across the lifespan. Given the association between alcohol use and/or abuse and the prevalence of STI/HIV-associated risk behaviors and adverse biological outcomes (i.e., STIs, including HIV) among African American females across the lifespan, there is a clear need to develop and evaluate prevention research efforts tailored for this subgroup.

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.

HIV Risk Behavior among Youth in the Dominican Republic: The Role of Alcohol and Other Drugs

Existing literature related to HIV in the Dominican Republic has tended to neglect the unique role of tourism areas as distinct ecologies facilitative of sexual risk behavior, particularly HIV vulnerability and transmission. Furthermore, limited attention has focused on Dominican adolescents living in close proximity to tourism areas who have become increasingly exposed to alcohol due to the expanding tourism industry in the Dominican Republic. While most previous analyses of the effects of alcohol on adolescent sexual risk behavior have focused on the transient effects of alcohol on judgment and decision making, the effects of chronic alcohol use on sexual behavior has been a neglected area of research. Our study explores the relationship between chronic alcohol use, the parent-adolescent relationship, affective factors such as self-esteem, and intentions to engage in sex. We examine the above factors within the context of tourism areas which represent a unique ecology of alcohol availability and consumption and HIV risk. We discuss implications for developing applied family-based programs to target Dominican adolescent alcohol use and sexual risk behavior in tourism areas of high alcohol exposure.

Longitudinal examination of alcohol use: a predictor of risky sexual behavior and Trichomonas vaginalis among African-American female adolescents

BACKGROUND

Alcohol use has been linked to risky sexual practices among adolescents. However, limited research on alcohol use and risky sexual behavior has been conducted on African-American female adolescents. This study examined high quantity of alcohol as a longitudinal predictor of risky sexual behavior and sexually transmitted diseases (STDs) among African-American female adolescents, a high-risk population for STDs.

METHODS

Three hundred ninety-three adolescent females, 15 to 21 years, were assessed on sociodemographics, alcohol use, and risky sexual behaviors. Participants also provided 2 swab specimens that were assayed for STDs. High quantity of alcohol use was defined as ≥ 3 drinks in 1 sitting.

RESULTS

Binary generalized estimating equation models were conducted assessing the impact of alcohol use at baseline on risky sexual behavior and STDs over a 12-month period. Age, intervention group, and baseline outcome measures were entered as covariates. The results indicated that high quantity of alcohol use predicted positive TV test results, inconsistent condom use, high sexual sensation seeking, multiple sexual partners, sex while high on alcohol or drugs, and having anal sex over a 12-month follow-up period.

CONCLUSIONS

These findings suggest that HIV/STD-related behavioral interventions for African-American adolescents should discuss the link between alcohol and HIV/STD-risk behavior. A deeper understanding is paramount to the development of efficacious prevention programs at individual and community levels.

Sexual risk reduction interventions for patients attending sexually transmitted disease clinics in the United States: a meta-analytic review, 1986 to early 2009

Sexually transmitted disease (STD) patients are more likely to experience a future STD including human immunodeficiency virus (HIV). The aim of this study was to examine the efficacy of behavioral interventions to reduce sexual risk behavior and incident STDs among patients attending STD clinics in the United States. A meta-analysis of 32 studies with 48 separate interventions targeting STD patients (N = 67,538) was conducted. Independent raters coded study, sample, and intervention characteristics. Effect sizes, using both fixed- and random-effects models, were calculated. Potential moderators of intervention efficacy were assessed. Relative to controls, intervention participants increased their condom use and had fewer incident STDs, including HIV, across assessment intervals (d (+)s ranging from 0.05 to 0.64). Several sample (e.g., age and ethnicity) and intervention features (e.g., targeting intervention to a specific group) moderated the efficacy of the intervention. Behavioral interventions targeted to STD clinic patients reduce sexual risk behavior and prevent HIV/STDs. Widespread use of behavioral interventions in STD clinics should be a public health priority.

Smoking behavior among low-income black adults: patterns and correlates of smoking trajectories

INTRODUCTION

Limited research has focused on identifying smoking patterns and correlates of cigarette use among low-income Blacks. Identifying smoking patterns and correlates of use would assist health providers to develop more culturally sensitive interventions.

METHODS

A semiparametric group-based trajectory modeling strategy was used to empirically identify patterns of cigarette use among 947 low-income Black adults (47% women) enrolled in a sexual risk reduction intervention at a sexually transmitted disease clinic. Patients' cigarette use was assessed 4 times over a 12-month period; correlates of cigarette use were examined.

RESULTS

Six smoking trajectories were empirically identified: none/rare smokers (n = 536), decreasing light smokers (n = 69), increasing light smokers (n = 51), low light smokers (n = 112), upper light smokers (n = 142), and moderate smokers (n = 33). Smoking trajectories were predicted by alcohol use, prior substance use treatment, marijuana use, and other illegal drug use, but the patterns varied by trajectory.

DISCUSSION

Results from this study show that Blacks' smoking patterns are associated with several risk factors. These findings suggest that development of prevention and cessation programs should be targeted to the specific needs of Blacks' smoking trajectories.

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

OBJECTIVES

High rates of psychosocial and health problems have been identified among patients attending sexually transmitted disease (STD) clinics, who are disproportionately urban, have low income, and are racial/ethnic minorities. This study sought to determine whether these problems co-occurred and whether they indicated the presence of a syndemic.

METHODS

Patients (N = 1557, 46% female, 64% African American) attending an urban STD clinic completed a computerized survey assessing childhood sexual abuse (CSA), depressive symptoms, binge drinking, marijuana use, intimate partner violence (IPV), and sexual risk behavior. Medical records were reviewed to determine incident STD diagnosis.

RESULTS

The psychosocial and health problems were interrelated. Endorsing more psychosocial problems was associated with a greater likelihood of having multiple sexual partners and STD diagnosis. Interactions between CSA and marijuana use and between CSA and IPV predicted STD diagnosis.

CONCLUSIONS

Numerous psychosocial and health problems co-occur among urban STD clinic patients. There was some evidence of a syngergistic relationship (i.e., a syndemic) between these conditions, resulting in worsened sexual health outcomes. Health care needs to be multidisciplinary to address the multiple psychosocial and health problems faced by STD clinic patients. Research needs to identify factors that may underlie these comorbid conditions.

Predicting condom use among STD clinic patients using the Information - Motivation-Behavioral Skills (IMB) model

We assessed determinants of condom use postulated by the IMB model among STD patients (N = 1474). The model provided acceptable fit to the data (CFI = 0.99, RMSEA = .04). Information was unrelated to condom use but had a negative effect on behavioral skills. Motivation had a positive effect on behavioral skills and condom use. Behavioral skills had a positive effect on condom use. In multiple-groups analyses, stronger associations between motivation and condom use were found among participants reporting no prior STD treatment. Interventions among STD patients should include activities addressing condom use motivation and directly enhancing condom skills.