Regularly Drinking Alcohol Before Sexual Activity in a Nationally Representative Sample: Prevalence, Sociodemographics, and Associations With Psychiatric and Substance Use Disorders

College students' perceptions of positive and negative drinking-related sexual experiences

Objective: During young adulthood, drinking and sexual behaviors are both normative and inextricably linked. While this association is well documented, little is known about how students define positive and negative drinking-related sexual experiences. Methods: Thirty-five undergraduates participated in a focus group about sexual experiences in the context of drinking. Thematic analysis was utilized to identify themes in the data. Results: Students' descriptions of positive drinking-related sexual encounters included having a good time, feeling safe, maintaining control over alcohol, as well as feeling safe in drinking contexts where sexual partners are located. Students' perceptions of negative experiences included specific consequences such as a damaged reputation, loss of control due to alcohol, and concern of engagement in sex when they or a partner was too intoxicated to consent. Conclusion: Gaining a better understanding of how college students view positive and negative drinking-related sexual experiences could inform interventions aimed at promoting student well-being.

Predictors of STD Screening From the Indigenist Stress-Coping Model Among Native Adults With Binge Substance Use

Objective

The American Indian/Alaska Native (AI/AN) population in the U.S. is thriving in spite of settler colonialist efforts of erasure. AI/AN people, however, continue to experience persistent health disparities including a disproportionate burden of substance use and sexually transmitted diseases/infections (STDs/STIs), as well as a disproportionate lack of public health STD screening services and STD prevention interventions grounded in AI/AN social contexts, experiences, and epistemologies. The present study explored how stressors and protective factors based on the Indigenist Stress Coping framework predict STD screening outcomes among Native adults.

Methods

We analyzed baseline self-report data from 254 Native adults ages 18-55 years with recent binge substance use who were enrolled in an evaluation of "EMPWR," a two-session STD risk reduction program in a rural, reservation-based community in the U.S. Southwest. Logistic regression models with robust variance were used to estimate odds ratios of lifetime STD testing for the theoretical stressors and cultural buffers.

Results

A little over half the sample were males (52.5%, n = 136), with a mean age of 33.6 years (SD = 8.8). The majority (76.7%, n = 195) reported having ever been screened for STD in their life. Discrimination score were significantly associated with lifetime STD testing: The higher discrimination was associated with lower odds of STD testing in the fully adjusted model (aOR = 0.40, 95%CI: 0.18, 0.92). The effects of AI/AN-specific cultural buffer such as participation in traditional practices on STD testing outcomes was in the expected positive direction, even though the association was not statistically significant. Household size was significantly associated with STD screening: The higher the number of people lived together in the house, the higher the odds of STD testing in the fully adjusted model (aOR = 1.19, 95%CI: 1.04, 1.38).

Conclusion

Our findings suggest that STD prevention programs should take into consideration AI/AN-specific historical traumatic stressors such as lifetime discrimination encounters and how these interact to drive or discourage sexual health services at local clinics. In addition, larger household size may be a protective factor functioning as a form of social support, and the extended family's role should be taken into consideration. Future research should consider improvement in measurements of AI/AN enculturation constructs.

Impacts of the respecting the circle of life teen pregnancy prevention program on risk and protective factors for early substance use among native American youth

BACKGROUND

Early substance use disproportionately impacts Native American (Native) youth and increases their risk for future abuse and dependence. The literature urges for interventions to move beyond focusing on single risk behaviors (e.g. substance use) and instead have capacity to improve health risk behaviors co-occuring during adolescence, particularly among Native populations for whom few evidence-based interventions (EBI) exist. We evaluated the effectiveness of the Respecting the Circle of Life program (RCL) on risk and protective factors for early substance use. RCL is a culturally tailored EBI shown to improve sexual health outcomes among Native youth.

METHODS

We conducted secondary analyses of data collected through a community-based randomized controlled trial of RCL evaluated among Native youth (ages 11-19) residing on a rural reservation between 2015-2020 (N = 534, 47.4 % male). We used linear regression, controlling for baseline age and sex, to test between study group differences in outcomes at 3-, 9-, and 12-month post-intervention. Models were stratified by sex and age (11-12, 13-14, and 15+ years of age) to examine differences within these subgroups.

RESULTS

Youth receiving RCL reported lower intention to use substances through 12-months follow-up (p = 0.006). Statistically significant improvements were also observed across peer, parent, and sexual partner risk and protective factors to delay substance use initiation, with notable differences among boys and participants ages 13-14.

CONCLUSIONS

RCL is a primary prevention, skills-based program effective in preventing risks for substance use. This evaluation underscores the value in developing programs that influence concurrent adolescent risk behaviors, especially for Native communities who endure multiple health disparities.

Substance use in a sexual context: The association of sex-related substance use motives with substance choice and use behaviors

BACKGROUND

Substance use before sex is associated with riskier behaviors. Sex-related substance use motives may explain pre-sex substance use. We explored what sex-related motives are associated with alcohol versus drug use, and which motives underlie heavier use.

METHODS

A sample of 936 participants (50% male, 80% White) completed an Internet survey about sexuality. Those who drank before sex (n=657) reported on six sex-related drinking motives; those who used drugs before sex (n=271) reported on six (parallel) sex-related drug use motives. The frequency of endorsement of each motive between drinkers and drug users was compared with z-distributions. Logistic regressions assessed whether motives were associated with substance use frequency and intoxication before sex.

RESULTS

Substance use to relax and to get a sex partner to use were more commonly endorsed for alcohol than drugs; substance use to improve performance and enhance experience were more commonly endorsed for drugs. Most motives were associated with alcohol frequency and intoxication before sex. None were associated with drug frequency; some were associated with drug intoxication.

CONCLUSIONS

Alcohol was generally used to facilitate sex, and drugs to enhance sex. Sex-related drinking motives were associated with drinking before sex; sex-related drug use motives were less predictive.

Unwanted Sex Due to Intoxication among Australians Aged 16-69 Years

Intoxication can be a factor in unwanted sex, but research on the extent of the issue in both women and men is limited. We assessed the prevalence, correlates, and 10-year time-trends of unwanted sex due to intoxication among a representative sample of 4,279 women and 3,875 men aged 16-69 years in Australia and considered how these vary by gender. In 2012-13, 16% of women and 10% of men reported ever having had a sexual experience when they "did not want to because they were too drunk or high at the time." For both women and men, this was associated with younger age, bisexual activity, and reports of lifetime injection drug use, sexually transmitted infections, and forced sex. Among women only, it was associated with drinking above guideline levels and ever having terminated a pregnancy. Among men only, it was associated with current tobacco smoking, elevated psychosocial distress, and poor general health. Compared with 2001-02 data, fewer men reported unwanted intoxicated sex, while there were no changes for women as a whole. Interpreting these findings through an intersectional assemblage framework supports stronger understanding of the multiple factors influencing sexuality and substance use with implications for promoting equity, safety, and sexual health.

How Does Alcohol Consumption Affect Perceptions of One's Own and a Drinking Partner's Ability to Consent to Sexual Activity?

In this naturalistic study, our aim was to examine the extent to which alcohol consumption affected perceptions of one's own and one's friend's ability to consent to sexual activity. We surveyed 160 adult bargoers in pairs about their own and their friends' alcohol consumption, intoxication symptoms, and ability to consent to sexual activity. On average, participants reported consuming 4.97 drinks, rated themselves at the legal limit for driving, reported one intoxication symptom, and had a blood alcohol concentration (BAC) just over .08. However, few thought they or their friend had diminished cognitive function. Accordingly, most indicated that they could consent to sex (93%) and their friend could consent to sex (87%). Number of drinks people reported consuming, self-reported intoxication levels and symptoms, and BACs were significantly correlated; however, none of these measures was significantly related to individuals' perceptions of their own or their friends' ability to consent to sexual activity. Finally, those in man-man pairs were significantly more likely than those in woman-woman pairs to indicate they would allow their friend to have sex if approached by an interested party. These findings have potential implications for prevention programming and for legal cases involving individuals who engage in sexual activity while intoxicated.

Sexual orientation and sex-related substance use: The unexplored role of bisexuality

Using alcohol and drugs in sexual contexts is associated with negative health consequences, including increased risk for HIV/STIs, sexual victimization, unplanned pregnancies, and overdose. Evidence suggests millions of adults regularly use alcohol in sexual contexts, thus increasing their risk for these consequences. However, no nationally representative estimates exist for rates of regular alcohol and/or drug use in sexual contexts. Additionally, previous studies suggest sexual minority individuals are more likely to use substances in sexual contexts than heterosexuals; however, none of these studies examined for multiple dimensions or subgroups of sexual orientation. Thus, using two distinct datasets-one large, nationally representative sample (N = 17,491) and an Internet-collected convenience sample (N = 1001)-we explored the associations between sexual orientation (dimensions and subgroups) and rates of regular sex-related alcohol and/or drug use in American adults. Results showed that sexual minority individuals were significantly more likely to report regularly using substances in sexual contexts compared to heterosexuals; however, results varied based on dimension of sexual orientation and by sex. Across both samples, bisexual individuals exhibited the highest rates of regular sex-related substance use. Findings suggest that sexual minorities, and bisexual individuals in particular, may be at increased risk for regular sex-related substance use and its associated negative health consequences. Future research should include nuanced and multidimensional assessments of sexual orientation to investigate sex-related alcohol and/or drug use and its associated risks, as well as examine the potential direct and indirect pathways by which these disparities may be conferred.

Associations between young adult men's patterns of alcohol use and sexual behavior: A latent profile analysis of two independent samples

Men's alcohol consumption and casual sexual behavior peak in early adulthood. Although there is a strong positive association between these behaviors, most studies have utilized a between-subjects approach rather than a person-centered approach to assess this relationship. A person-centered approach allows for an examination of subgroups of drinkers that may differ in their casual sexual behaviors. To address this gap, secondary data analyses were conducted with two independent samples totaling 906 men between the ages of 18 and 29 from the Midwestern United States. In both studies, participants reported their alcohol expectancies and consumption, sexual behaviors, and sexual attitudes. Multiple group latent profile similarity analyses were conducted using the alcohol-related variables. Four similar profiles emerged in both samples; thus, the data were combined. Casual sex-related variables were then examined in relation to the profiles. The two lighter drinking groups differed from one another in their alcohol consumption and sexual attitudes; however, they did not differ in their alcohol expectancies or number of sex partners. The two heavier drinking groups differed from one another in their liquid courage expectancies, alcohol consumption, one-time-only partners, and sexual attitudes; however, they did not differ from each other in their sex-drive expectancies or lifetime partners. Person-centered approaches can be used to develop more tailored interventions, particularly for those at greater risk for the negative health consequences of engaging in sexual behavior with multiple one-time-only partners.

Documentation of Sexual History by Psychiatry Postgraduate Trainees: Lessons to Be Learnt

Aim: The author reports on whether sexual history was documented in files of persons with alcohol-use disorders as part of initial intake by psychiatry postgraduate trainees.

Methodology: Chart review of files of persons with alcohol use disorders.

Results: A total of 53 charts were reviewed to determine whether sexual history was documented. Sexual history was not documented in 79.24% of the files as part of the initial psychiatric intake.

Conclusions: Postgraduate psychiatric trainees do not document sexual history in files of persons with alcohol-use disorders as part of initial intake. This is an important issue to be addressed as part of postgraduate psychiatry training.

Associations between sociodemographic characteristics and substance use disorder severity among methamphetamine-using men who have sex with men

Background: Men who have sex with men (MSM) have elevated rates of substance use disorders (SUDs) and differences across sociodemographic sub-groups of MSM are associated with a greater risk of deleterious outcomes. Although studies have shown that MSM report greater rates of polysubstance use relative to other adult populations, the associations between sociodemographic characteristics and both acute substance use and substance use severity among methamphetamine-using MSM are unknown. Objectives: The present study examines associations between sociodemographic characteristics and (a) recent substance use and (b) SUD severity. Method: From March 2014 to January 2016, 286 methamphetamine-using MSM were recruited to complete a baseline Audio Computer-Assisted Self-Interview (ACASI) assessment and the SCID MINI. Multivariable analyses employed generalized structural equation modeling given the non-continuous nature of the endogenous variables. Results: All measured sociodemographic characteristics except gay self-identification were significantly associated with recent substance use (all ps ≤ .05), and all characteristics except current homelessness were significantly associated with diagnostic SUD severity (all ps ≤ .05). However, nuanced risks were observed in participants' use of specific substances regarding recent substance use and substance use severity. Conclusion: These results suggest that multiple factors contribute to the risks of SUD severity among methamphetamine-using MSM. As such, these results are useful in the tailoring of clinical and psychosocial intervention strategies that serve this and other high-risk populations.

Substance use disorders and sexual behavior; the effects of alcohol and drugs on patients' sexual thoughts, feelings and behavior

INTRODUCTION

Hardly any research exists on the relationship between substance use and sexual behaviors in patients with a substance use disorder. This study aimed to examine this relation by looking into perceived positive effects on sexual behavior, perceived negative effects and risky sexual behavior due to substance use in patient groups of users of alcohol, stimulants, sedatives and Gamma hydroxybutyrate (GHB). In addition, the current study aimed to address the question whether sexual behavior (e.g. number of sexual partners, sexual activity) differs between these patient groups.

METHOD

A total of 180 patients with a substance use disorder (i.e. alcohol, amphetamine, cannabis, cocaine, GHB and opiates) participated. A self-report questionnaire was administered with questions on substance use, sexual behaviors (e.g. sexual activity, masturbation, use of pornography) and statements about the perceived changes in sexual functioning and behavior under influence of the primary substance of abuse.

RESULTS

All four groups reported changes in sexual thoughts, feelings and behavior due to the use of their primary substance. More than half of the patients reported enhancements in sexual domains (i.e. sexual pleasure, sexual arousal, sexual behavior), but also decrements or risky behaviors and about a quarter stated that their sexual thoughts, feelings and behaviors were often associated with the use of their primary substance of abuse. Patients with a GHB use disorder reported the strongest relation between drug use and sexual behavior. Users of GHB not only reported more enhancement in several sexual domains, but also less decline in sexual domains compared to the other patient groups and more risky behavior or more sexual activity than some of the other groups of patients.

CONCLUSIONS

The results underline the importance of addressing the relationship between substance use and sexual behavior in treatment programs, as patients may be hesitant to stop their use of substances when they experience many positive effects in their sexual behavior. Future research directions are suggested.

Increased Partner Risk Characteristic Among Adolescents Using Alcohol In the Moment

BACKGROUND

Alcohol is a recognized risk factor for sexually transmitted diseases acquisition, but the mechanism is unclear. Potentially, adolescents using alcohol in the 2 hours before sex (in-the-moment use) have riskier sexual partners.

METHODS

We used multivariable logistic regression to examine the association between in-the-moment alcohol use and partner risk characteristics reported for the most recent sex among primarily 17- to 18-year-old adolescents originally recruited from a representative sample of Chicago public elementary schools. We created 3 composite partner risk profiles: partner familiarity risk (casual and unexpected), partner context risk (age discordance and met in public), and overall risk using all measures except partner alcohol use.

RESULTS

Teens who reported any in-the-moment alcohol use were more likely than nondrinking teens to report casual (adjusted odds ratio [AOR], 3.2; 95% confidence interval [95% CI], 2.1-4.9), unexpected (AOR, 1.6; 95% CI, 1.0-2.5), age discordant (AOR, 3.0; 95% CI, 2.0-4.6), or met in public partners (AOR, 1.4; 95% CI, 1.0 to 2.1). For each composite measure, the number of partner risk characteristics reported increased linearly with the percent of teens drinking in the moment (Cochran-Armitage trend, P < 0.0001). Compared with zero characteristics, in-the-moment alcohol use was associated with increased odds of reporting 1 (AOR, 2.8; 95% CI, 1.7-4.5), 2 (AOR, 4.6; 95% CI, 2.7, 7.6), or 3 to 4 characteristics (AOR, 7.1; 95% CI, 3.3-15.3).

CONCLUSIONS

Our findings expand the link between in-the-moment alcohol use and partner risk reported in prior studies to encompass adolescents' general sexual experiences and additional partner characteristics including the highly associated composite characteristics.

Sex-related substance use and the externalizing spectrum

BACKGROUND

Substance use before and during sexual activity is associated with many negative health outcomes. Estimates suggest that at least 4.3 million American adults annually engage in regular sex-related alcohol consumption, indicating that the intersection of substance use and sexual behavior is of public health concern. However, it is likely that when considering broader sex-related substance use, estimates would be notably higher. While substance use disorders and antisocial personality disorder have been associated with sex-related alcohol consumption, no study has investigated how regular sex-related substance use is associated with the broader transdiagnostic externalizing spectrum. Further, no studies have assessed whether or not sexual risk-taking behaviors can be integrated into the externalizing spectrum.

METHODS

In a large internet sample (N=936), we used confirmatory factor analysis, item response theory, and logistic regression to link sex-related alcohol and drug use to an externalizing latent variable; identified psychometric characteristics of these behaviors; and determined the extent to which one's externalizing level was associated with changes in odds of regular sex-related substance use. We then replicated these findings in a nationally representative sample (N=34,653).

RESULTS

Results highlighted the close association between sex-related substance use and externalizing, with externalizing increases being associated with significantly increased odds of regular sex-related substance use.

CONCLUSIONS

These findings bear notable implications for conceptualization and treatment of sex-related substance use. Transdiagnostic intervention can be an efficient means of addressing this problematic behavior as well as other comorbid presentations. Results expand the current conceptualization of the externalizing spectrum.

A Place for Sexual Dysfunctions in an Empirical Taxonomy of Psychopathology

Sexual dysfunctions commonly co-occur with various depressive and anxiety disorders. An emerging framework for understanding the classification of mental disorders suggests that such comorbidity is a manifestation of underlying dimensions of psychopathology (or "spectra"). In this review, we synthesize the evidence that sexual dysfunctions should be included in the empirical taxonomy of psychopathology as part of the internalizing spectrum, which accounts for comorbidity among the depressive and anxiety disorders. The review has four parts. Part 1 summarizes the empirical basis and utility of the empirical taxonomy of psychopathology. Part 2 reviews the prima facie evidence for the hypothesis that sexual dysfunctions are part of the internalizing spectrum (i.e., high rates of comorbidity; shared cognitive, affective, and temperament characteristics; common neural substrates and biomarkers; shared course and treatment response; and the lack of causal relationships between them). Part 3 critically analyzes and integrates the results of the eight studies that have addressed this hypothesis. Finally, Part 4 examines the implications of reconceptualizing sexual dysfunctions as part of the internalizing spectrum, and explores avenues for future research.

Borderline personality disorder and regularly drinking alcohol before sex

INTRODUCTION AND AIMS

Drinking alcohol before sex increases the likelihood of engaging in unprotected intercourse, having multiple sexual partners and becoming infected with sexually transmitted infections. Borderline personality disorder (BPD), a complex psychiatric disorder characterised by pervasive instability in emotional regulation, self-image, interpersonal relationships and impulse control, is associated with substance use disorders and sexual risk behaviours. However, no study has examined the relationship between BPD and drinking alcohol before sex in the USA. This study examined the association between BPD and regularly drinking before sex in a nationally representative adult sample.

DESIGN AND METHODS

Participants were 17 491 sexually active drinkers from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Logistic regression models estimated effects of BPD diagnosis, specific borderline diagnostic criteria and BPD criterion count on the likelihood of regularly (mostly or always) drinking alcohol before sex, adjusted for controls.

RESULTS

Borderline personality disorder diagnosis doubled the odds of regularly drinking before sex [adjusted odds ratio (AOR) = 2.26; confidence interval (CI) = 1.63, 3.14]. Of nine diagnostic criteria, impulsivity in areas that are self-damaging remained a significant predictor of regularly drinking before sex (AOR = 1.82; CI = 1.42, 2.35). The odds of regularly drinking before sex increased by 20% for each endorsed criterion (AOR = 1.20; CI = 1.14, 1.27) DISCUSSION AND CONCLUSIONS: This is the first study to examine the relationship between BPD and regularly drinking alcohol before sex in the USA. Substance misuse treatment should assess regularly drinking before sex, particularly among patients with BPD, and BPD treatment should assess risk at the intersection of impulsivity, sexual behaviour and substance use. [Thompson Jr RG, Eaton NR, Hu M-C, Hasin DS Borderline personality disorder and regularly drinking alcohol before sex Drug Alcohol Rev 2017;36:540-545].

Effects of the "Circle of Life" HIV-prevention program on marijuana use among American Indian middle school youths: a group randomized trial in a Northern Plains tribe

BACKGROUND

Early substance use threatens many American Indian/Alaska Native (AI/AN) communities, as it is a risk factor for maladaptive use and adverse health outcomes. Marijuana is among the first substances used by AI/AN youth, and its use becomes widespread during adolescence. Interventions that delay or reduce marijuana use hold the promise of curbing substance disorders and other health risk disparities in AI/AN populations.

OBJECTIVES

We evaluated the effectiveness of the Circle of Life (COL) program in reducing marijuana use among young AI adolescents. COL is a culturally tailored, theory-based human immunodeficiency virus (HIV) and sexually transmitted disease (STD) intervention shown to delay sexual initiation among AI youths.

METHODS

We conducted secondary analyses of data from a school-based group randomized trial conducted between 2006 and 2007 in all 13 middle schools on a rural, Northern Plains reservation (N = 635, 47% female). We used discrete-time survival analysis (DTSA) to assess COL effectiveness on risk of marijuana initiation among AI youths and latent growth curve modeling (LGCM) to evaluate effects on frequency of marijuana use over time.

RESULTS

DTSA models showed that the overall risk of marijuana initiation was 17.3% lower in the COL group compared to the control group. No intervention effect on frequency of marijuana use emerged in LGCM analyses.

CONCLUSION

COL is a multifaceted, culturally tailored, skills-based program effective in preventing marijuana uptake among AI youth.

Emergency Department Visits for Adverse Drug Reactions Involving Alcohol: United States, 2005 to 2011

BACKGROUND

Alcohol consumption may interfere with absorption, distribution, metabolism, and excretion of medications and increase risk of adverse drug reactions (ADR). Studies report increasing prescription medication use over time, with many U.S. drinkers using alcohol-interactive medication. This study identified trends in incidence of U.S. emergency department (ED) visits for ADR with alcohol involvement (ADR-A), compared characteristics and disposition between ADR-A visits and ADR visits without alcohol involvement (ADR-NA), and examined frequency of implicated medications in such visits for 2005 to 2011.

METHODS

ADR visits were identified through the Drug Abuse Warning Network, a national surveillance system monitoring drug-related ED visits. Analysis accounted for sampling design effects and sampling weights. Estimates are presented for totals (ages 12+), age group, and/or sex. Trends were assessed by joinpoint log-linear regression. Differences between ADR-A and ADR-NA visits were compared using two-tailed Rao-Scott chi-square tests.

RESULTS

From 2005 to 2011, incidence of ADR-A visits increased for males and females ages 21 to 34 and females ages 55+. An average of 25,303 ADR-A visits ages 12+ occurred annually. Compared with ADR-NA visits, ADR-A visits were more likely to involve males, patients ages 21 to 54, and 2+ implicated drugs. Alcohol involvement increased odds of more serious outcomes from ADR visits. Central nervous system (CNS) agents were the most common medications in ADR-A visits (59.1%), with nearly half being analgesics (mainly opioid). About 13.8% of ADR-A visits involved psychotherapeutic agents, including antidepressants. Besides CNS and psychotherapeutic agents, ADR-A visits involved a higher percentage of genitourinary-tract agents (mainly for impotence) than ADR-NA visits. Sex and age variations were observed with certain implicated medications.

CONCLUSIONS

ED visits for alcohol-drug interactions can be prevented by avoiding alcohol when taking alcohol-interactive medications. Our results underscore the need for healthcare professionals to routinely ask patients about alcohol consumption and warn of ADR risks before prescribing and dispensing alcohol-interactive medications.

Testing the efficacy of a brief sexual risk reduction intervention among high-risk American Indian adults: study protocol for a randomized controlled trial

Background

American Indian adults are more likely to experience co-occurring mental health and substance use disorders than adults of other racial/ethnic groups and are disproportionately burdened by the most common sexually transmitted infections, namely chlamydia and gonorrhea. Several behavioral interventions are proven efficacious in lowering risk for sexually transmitted infection in various populations and, if adapted to address barriers experienced by American Indian adults who suffer from mental health and substance use problems, may be useful for dissemination in American Indian communities. The proposed study aims to examine the efficacy of an adapted evidence-based intervention to increase condom use and decrease sexual risk-taking and substance use among American Indian adults living in a reservation-based community in the Southwestern United States.

Methods/Design

The proposed study is a randomized controlled trial to test the efficacy of an adapted evidence-based intervention compared to a control condition. Participants will be American Indian adults ages 18–49 years old who had a recent episode of binge substance use and/or suicide ideation. Participants will be randomized to the intervention, a two-session risk-reduction counseling intervention or the control condition, optimized standard care. All participants will be offered a self-administered sexually transmitted infection test. Participants will complete assessments at baseline, 3 and 6 months follow-up. The primary outcome measure is condom use at last sex.

Discussion

This is one of the first randomized controlled trials to assess the efficacy of an adapted evidence-based intervention for reducing sexual risk behaviors among AI adults with substance use and mental health problems. If proven successful, there will be an efficacious program for reducing risk behaviors among high-risk adults that can be disseminated in American Indian communities as well as other rural and under-resourced health systems.

Trial Registration

Clinical Trials NCT02513225

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

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