Psychological distress, drug and alcohol use as correlates of condom use in HIV-serodiscordant heterosexual couples

HIV-serodifferent couples' perspectives and practices regarding HIV prevention strategies: A mixed methods study

A substantial proportion of heterosexually acquired HIV infections in the U.S. occur between partners in primary relationships characterized by mixed HIV status. The U.S. Centers for Disease Control and Prevention have issued guidelines prioritizing HIV-serodifferent couples for primary HIV prevention, including treatment-as-prevention and pre-exposure prophylaxis (PrEP). Yet, very little research has been conducted to understand the perspectives and practices of HIV-serodifferent couples regarding HIV prevention strategies in the U.S. To help fill this gap, we conducted a mixed methods study with 27 mostly Black/African American and Latinx HIV-serodifferent heterosexual couples residing in New York City to explore their knowledge, attitudes, practices, and perspectives regarding combination HIV prevention, including condoms, PrEP and viral control. All couples expressed the desire to maintain viral suppression in the HIV-positive partner, which was not always achieved. There was considerable heterogeneity in the use of HIV prevention methods by couples; and several patterns emerged that were largely driven by gender and relationship dynamics. Female partners, in particular, expressed high levels of anxiety around transmission of HIV and thus desired multiple methods of protection. Healthcare providers should consider couples' psychosocial well-being, relationship quality, and other motivational factors when helping to tailor HIV preventative care for mixed-status couples.

Socio- demographic correlates of HIV sero-discordance among couples in West Bengal, India; A cross sectional analysis

Serodiscordant couples serves as potential source of Human Immunodeficiency Virus (HIV) transmission. Understanding demographic dynamics of serodiscordant couples plays an important role in tailoring interventions towards eliminating HIV. We conducted this cross sectional analysis in 314 Integrated Counseling and Testing Centres (ICTCs) in West Bengal, India during April 2016 to March 2020. General individuals who were detected as HIV reactive and whose spouses were also tested for HIV comprised the study population (8740 couples). Sociodemographic variables were compared across concordant and discordant arms and also between male positive (M+ F-) and female positive (F+ M-) subgroups of serodiscordant. Among the couples studied, 35.2% (95% CI: 34.2- 36.2 %) were serodiscordant. Among serodiscordant couples, the proportion of M+ F- (86.1%) was significantly higher than F+ M- (13.9%). We observed higher mean ages of couples, higher education, business & service occupations and urban residence as significantly associated with serodiscordance relationship (p < 0.05). Higher mean age of couple and lower proportion of housewives were associated with F+M- subgroup. As around 35% serodiscordant couples carry the risk of transmission to negative spouses particularly in higher age and urban residence, thus reorientation of HIV programme may be required accordingly to avert transmission in future.

Anxiety symptoms and disorders among adults living with HIV and AIDS: A critical review and integrative synthesis of the empirical literature

There are over 35 million people worldwide infected with the Human Immunodeficiency Virus (HIV) and its progression to Acquired Immunodeficiency Syndrome (AIDS; WHO, 2014). With the advent of combined antiretroviral therapy (i.e., cART) in 1996, persons living with HIV/AIDS (PLWHA) now have much longer life expectancies. However, living with HIV remains challenging, as it is associated with a number of significant and recurrent (chronic) stressors including physical pain, side effects of cART, social stigma, and discrimination, among other social stressors. Presumably, as a result of these types of stressors, a disproportionately high number of PLWHA struggle with clinically-significant psychiatric symptoms and disorders. Although much scientific and clinical attention has focused on depressed mood and psychopathology among PLWHA, there has been comparably less focus on anxiety and its disorders. The paucity of work in this area is concerning from a public health perspective, as anxiety symptoms and disorders are the most common class of psychiatric disorders and often maintain a large negative impact on life functioning.

Social and psychological correlates of unprotected anal intercourse among Hispanic-American women: implications for STI/HIV prevention

Heterosexual anal intercourse is associated with increased risk for HIV and other sexually transmitted infections. Research on the social and psychological risk factors associated with heterosexual unprotected anal intercourse among Hispanic women in the USA is limited. We examined demographic, mental health, relationship power, sexual self-efficacy, self-esteem, acculturation and HIV knowledge as correlates of unprotected anal intercourse among 514 HIV-negative Hispanic women, 18 to 59 years of age, residing in one urban county in southern Florida. In both unadjusted and adjusted results, the likelihood of engaging in unprotected anal intercourse was associated with food insecurity in the past 30 days (adjusted odds ratio [AOR] = 1.57, 95% confidence interval [CI] 1.03, 2.40) and more interpersonal power attributed to the male partner (AOR = 1.63, 95%CI 1.08, 2.45). Not significant, yet of possible importance, were ever having engaged in exchange sex (AOR = 1.96, 95%CI = 0.97, 3.98) and lower HIV knowledge (AOR = 0.80, 95%CI = 0.63, 1.01). Interventions aimed at reducing heterosexual unprotected anal intercourse risk for HIV infection among Hispanic women may benefit by addressing socioeconomic and interpersonal issues, and assessing HIV knowledge and comprehension.

Negative Affect and Risk for Human Immunodeficiency Virus: One Size May Not Fit All

Purpose.

Research examining the relationship between human immunodeficiency virus (HIV)-related risk behavior and negative affective states has netted mixed findings. The present study examined the potential moderating role of gender and sexual orientation on negative affect and HIV-related risk behavior.

Design.

Measures of depression, anxiety, and HIV-related risk behavior were collected from participants at the time of pretest counseling. Analysis of variance was used to examine HIV-related risk behavior as a function of negative affect levels and gender and behavioral sexual orientation.

Setting.

The study was conducted through a community-based, anonymous HIV counseling and testing site.

Subjects.

Participants included 185 consecutively recruited men and women presenting for HIV testing.

Measures.

Participants completed a structured interview regarding HIV-related risk behavior, the Center for Epidemiological Studies Depressed Mood Scale, and the Beck Anxiety Inventory.

Results.

Greater HIV-related risk behavior was associated with high levels of anxiety and moderate or high levels of depression for bisexual women. Greater HIV-related risk behavior was also associated with low levels of anxiety and mild to moderate levels of depression for bisexual men.

Conclusions.

The relationship between negative affective states and HIV-related risk behavior may vary as a function of gender and behavioral sexual orientation. Better understanding of the relationship between negative affect and risk behavior may be achieved through consideration of these sources of variation.

Determinants of Safer Sexual Behavior in a Long-term HIV-seropositive Population

Determinants of safer sexual behaviors among HIV-infected adult men with hemophilia were examined. A model was proposed that personal adjustment, communication skills, self-efficacy, and perceived advantages of condom use would influence safer sex practices. The model was tested with 181 men with hemophilia and HIV infection from 27 hemophilia treatment centers across the United States. The hypothesized model was tested using LISREL and explained 35 percent of the variance in safer sexual behaviors. Personal adjustment was significantly associated with general communication skills. General communication was linked with communication about safer sex which, in turn, influenced self-efficacy and perceived advantages of condom use. Communication about safer sex, efficacy and perceived advantages of condom use were all directly related to safer sexual behaviors.

Condom effectiveness in reducing heterosexual HIV transmission: a systematic review and meta-analysis of studies on HIV serodiscordant couples

OBJECTIVE

This systematic review and meta-analysis aimed to reassess the effectiveness of condoms in reducing heterosexual transmission of HIV.

METHODS

Medline, Scopus, and the ISI Web of Science databases were searched up to June 2014. Eligible studies were synthesized using random-effects models.

RESULTS

Twenty-five studies with 10,676 HIV serodiscordant heterosexual couples were analyzed. The risk of HIV transmission was considerably lower among couples that were always using condoms compared to never-users (RR: 0.29, 95% CI: 0.20-0.43) or inconsistent users (RR:  0.23, 0.13-0.40). The protective effect was slightly higher when the male rather than the female partner was infected (RR: 0.31, 0.20-0.48; vs. RR: 0.44, 0.24-0.80), and very high in Asian settings (RR: 0.06, 0.01-0.46).

CONCLUSIONS

Though imperfect, condoms reduce HIV transmission by more than 70% when used consistently by HIV serodiscordant heterosexual couples. Social, cultural and biological differences need to be studied further to inform projection modelers and policy makers.

Qualitative study of the influence of antidepressants on the psychological health of patients on antiretroviral therapy in Uganda

The study set out to explore how HIV-positive individuals conceptualise and describe depression and its manifestation in their lives, and how this may change over time in the context of antiretroviral therapy (ART) and antidepressant treatment. We conducted in-depth interviews using a semi-structured interview guide with 26 adult HIV-positive clients receiving ART in Uganda. We asked the participants to describe their depression and its impact on their general health, physical functioning and psychological wellbeing, as well as the influences of receiving ART or antidepressant treatment. Although depressive experience among the patients was largely described in terms of criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), some of the symptoms used to describe depression, such as 'thinking too much' or worrisome thoughts, did not fit into the DSM-IV criteria. The participants attributed their depression to news of the HIV diagnosis, a fear of dying, the potential socioeconomic consequences of their HIV infection on their family, ART side-effects and continued bad health. Their subjective reports indicated that the treatment of depression with antidepressants had made a positive impact on their general and psychological health. These findings highlight the need for models of HIV care that integrate mental health services and promote the diagnosis and treatment of depression in culturally sensitive ways so as to improve the quality of life and health outcomes for clients. However, keeping the particular study design in mind, these findings should be interpreted as preliminary.

Effectiveness of antidepressants and predictors of treatment response for depressed HIV patients in Uganda

Antidepressant medication is well established for the treatment of depression but little is known about its effectiveness for HIV populations in sub-Saharan Africa. This study examined the effectiveness of antidepressant treatment and predictors of treatment response among depressed HIV patients in Uganda. Data were obtained from two open-label trials in which 184 HIV patients were diagnosed with depression and started on antidepressants. Data at treatment baseline and month 6 were compared to assess treatment response, and baseline predictors of response were assessed. A total of 154 completed month 6, of whom 122 (79%) had responded to treatment and were no longer depressed (Patient Health Questionnaire-9, score < 5). Bivariate analysis found that education, CD4 count, general health functioning, physical health, pain, quality of life and social support variables were associated with antidepressant treatment response; however, only secondary education and social support independently predicted treatment response in logistic multiple regression analysis. Baseline depression severity was not associated with treatment response. In conclusion, antidepressants are effective in treating both moderate and more severe depression among persons living with HIV in Uganda, and education [OR (95% CI) = 4.33 (1.33-14.11)] and social support [OR (95% CI) = 1.54 (1.03-2.30)] were most predictive of treatment response.

INtegration of DEPression Treatment into HIV Care in Uganda (INDEPTH-Uganda): study protocol for a randomized controlled trial

BACKGROUND

Despite 10 to% of persons living with HIV in sub-Saharan Africa having clinical depression, and the consequences of depression for key public health outcomes (HIV treatment adherence and condom use), depression treatment is rarely integrated into HIV care programs. Task-shifting, protocolized approaches to depression care have been used to overcome severe shortages of mental health specialists in developing countries, but not in sub-Saharan Africa and not with HIV clients. The aims of this trial are to evaluate the implementation outcomes and cost-effectiveness of a task-shifting, protocolized model of antidepressant care for HIV clinics in Uganda.

METHODS/DESIGN

INDEPTH-Uganda is a cluster randomized controlled trial that compares two task-shifting models of depression care--a protocolized model versus a model that relies on the clinical acumen of trained providers to provide depression care in ten public health HIV clinics in Uganda. In addition to data abstracted from routine data collection mechanisms and supervision logs, survey data will be collected from patient and provider longitudinal cohorts; at each site, a random sample of 150 medically stable patients who are depressed according to the PHQ-2 screening will be followed for 12 months, and providers involved in depression care implementation will be followed over 24 months. These data will be used to assess whether the two models differ on implementation outcomes (proportion screened, diagnosed, treated; provider fidelity to model of care), provider adoption of treatment care knowledge and practices, and depression alleviation. A cost-effectiveness analysis will be conducted to compare the relative use of resources by each model.

DISCUSSION

If effective and resource-efficient, the task-shifting, protocolized model will provide an approach to building the capacity for sustainable integration of depression treatment in HIV care settings across sub-Saharan Africa and improving key public health outcomes.

TRIAL REGISTRATION

INDEPTH-Uganda has been registered with the National Institutes of Health sponsored clinical trials registry (3 February 2013) and has been assigned the identifier NCT02056106.

Does effective depression treatment alone reduce secondary HIV transmission risk? Equivocal findings from a randomized controlled trial

Depressed mood has been associated with HIV transmission risk behavior. To determine whether effective depression treatment could reduce the frequency of sexual risk behavior, we analyzed secondary outcome data from a 36-week, two-arm, parallel-design, randomized controlled trial, in which homeless and marginally housed, HIV-infected persons with comorbid depressive disorders were randomized to receive either: (a) directly observed treatment with the antidepressant medication fluoxetine, or (b) referral to a local public mental health clinic. Self-reported sexual risk outcomes, which were measured at 3, 6, and 9 months, included: total number of sexual partners, unprotected sexual intercourse, unprotected sexual intercourse with an HIV-uninfected partner or a partner of unknown serostatus, and transactional sex. Estimates from generalized estimating equations regression models did not suggest consistent reductions in sexual risk behaviors resulting from treatment. Mental health interventions may need to combine depression treatment with specific skills training in order to achieve durable impacts on HIV prevention outcomes.

Depression and sexual risk behaviour among clients about to start HIV antiretroviral therapy in Uganda

We investigated depression in relationship to sexual risk behaviour with primary partners among HIV-positive clients in Uganda. Baseline data were analyzed from a cohort of clients starting antiretroviral therapy. The Patient Health Questionnaire (PHQ-9) was used to classify depressive severity (none, minor and major depression) and symptom type (cognitive and somatic). Condom use was assessed over the past six months and during the last episode of sexual intercourse. A total of 386 participants had a primary sex partner, with whom 41.6% always used condoms during sex over the past six months, and 62.4% during last sex. Use of a condom during last sex was associated with having no depression and lower PHQ-9 total and cognitive and somatic subscale scores in bivariate analyses; most of these relationships were marginally significant for intercourse over the past six months. Controlling for demographics, HIV disclosure and partner HIV status, only minor depression was associated with unprotected sex. Depressive symptoms, even if not a clinical disorder, warrant early detection and treatment for promoting HIV prevention among HIV-affected couples.

Prevalence of inconsistent condom use and associated factors among HIV discordant couples in a rural county in China

A random sample consisting of 88 sexually active people living with HIV (PLWH) and their HIV negative spouses in rural China were interviewed. Data of 68 couples (77.2 %) who gave identical responses to whether they had been using condoms consistently in the last 12 months (n = 136) were analyzed. The results showed that 27.9 % of the discordant couples used condom inconsistently in the last year. Condom non-availability was the most commonly given main reason for not using condoms. Free condoms should be made available to these low-income couples. Suicidal ideation of the PLWH and the spouse's perception on 'whether someone could contract HIV via unprotected sexual intercourse with a HIV positive person' were significantly associated with inconsistent condom use in the last year. Education program should change the cognition about the risk for HIV transmission via unprotected sex. Integrated psychological services to reduce suicidal ideation are greatly warranted.

Substance use is a risk factor for neurocognitive deficits and neuropsychiatric distress in acute and early HIV infection

The acute and early stages of HIV infection (AEH) are characterized by substantial viral replication, immune activation, and alterations in brain metabolism. However, little is known about the prevalence and predictors of neurocognitive deficits and neuropsychiatric disturbances during this period. The present study examined the impact of demographic, HIV disease, and substance use factors on HIV-associated neurocognitive impairment and self-reported neuropsychiatric distress among 46 antiretroviral-naive adults with median duration of infection of 75 days relative to a sample of 21 HIV seronegative (HIV-) adults with comparable demographics and risk factors. Participants were administered a brief neurocognitive battery that was adjusted for demographics and assessed executive functions, memory, psychomotor speed, and verbal fluency, as well as the Profile of Mood States, a self-report measure of neuropsychiatric distress. Odds ratios revealed that AEH participants were nearly four times more likely than their seronegative counterparts to experience neurocognitive impairment, particularly in the areas of learning and information processing speed. Similarly, AEH was associated with a nearly fivefold increase in the odds of neuropsychiatric distress, most notably in anxiety and depression. Within the AEH sample, HIV-associated neurocognitive impairment was associated with problematic methamphetamine use and higher plasma HIV RNA levels, whereas neuropsychiatric distress was solely associated with high-risk alcohol use. Extending prior neuroimaging findings, the results from this study indicate that HIV-associated neurocognitive impairment and neuropsychiatric distress are highly prevalent during AEH and are associated with high-risk substance use.

Impact of HIV antiretroviral therapy on depression and mental health among clients with HIV in Uganda

OBJECTIVE

With wide-reaching harmful effects of depression, and the absence of psychiatric treatment in most HIV care programs in sub-Saharan Africa, we examined the effects of antiretroviral therapy (ART) on depression and other mental health indicators.

METHODS

602 patients (302 non-ART, 300 ART) were followed for the first 12 months of HIV care in Uganda, with assessments at entry into care and Months 6 and 12. Mental health was assessed with measures of depression, hopelessness, and internalized HIV stigma; physical health functioning was assessed as an explanatory variable.

RESULTS

Thirteen percent had clinical depression, 57% had elevated depressive symptoms, and CD4 cell count was negatively correlated with measures of depression at baseline. Significant reductions in elevated depressive symptoms (time: odds ratio [95% confidence interval] = 0.53 [0.43-0.64]) and hopelessness (time: β = -0.12, p < .001) were observed in both the ART and non-ART groups, but the drop in depression was greater among ART patients in intention-to-treat multivariate analysis (ART × time: p < .001). When added to the regression models, change in physical health functioning predicted positive longitudinal change on measures of depression, hopelessness, and internalized stigma (all p values < .001), yet ART status remained a significant independent predictor of each (ART × time: p values ranged from < .05 to < .001). Most mental health benefits of ART were experienced in the first 6 months of care.

CONCLUSIONS

These findings demonstrate the mental health benefits of HIV care and ART. However, in some people, mental health problems persist once physical health is stabilized, in which case mental health treatment may be needed.

Does motivational interviewing counseling time influence HIV-positive persons' self-efficacy to practice safer sex?

OBJECTIVE

This study examined the impact of motivational interviewing (MI) counseling time on self-efficacy to practice safer sex for people living with HIV/AIDS (PLWHA).

METHODS

In 4 month intervals we followed a cohort of 490 PLWHA for 12 months. We conducted hierarchical linear regression models to examine changes in safer sex self-efficacy when participants received zero, low to moderate (5-131 min) and high (132-320 min) doses of MI time. We conducted a similar analysis using number of counseling sessions as the predictor variable.

RESULTS

Participants with low to moderate doses of MI counseling had 0.26 higher self-efficacy scores than participants with zero MI time (p=0.01). Also, they had 0.26 lower self-efficacy scores than participants with high amounts of MI time (p=0.04). Participants with high doses of MI had a 0.5 higher self-efficacy score than participants with zero amount of MI time (p<0.0001). Participants who received 3-4 counseling sessions had 0.41 greater self-efficacy scores than participants who did not receive any sessions (p<0.0001) but did not differ from participants receiving 1-2 sessions.

CONCLUSION

MI time is a key to enhancing safer sex self-efficacy among PLWHA.

PRACTICE IMPLICATIONS

Safer sex self-efficacy improves the more MI counseling time and sessions PLWHA receive.

The influence of depression on the progression of HIV: direct and indirect effects

The authors suggest a theoretical model of pathways of HIV progression, with a focus on the contributions of depression-as well as secondary, behavioral and emotional variables. Literature was reviewed regarding (a) comorbid depression and the direct physiological effects on HIV progression and (b) intermediary factors between HIV and disease progression. Intermediary factors included (a) substance use, (b) social support, (c) hopelessness, (d) medication nonadherence, and (e) risky sexual behavior and the contraction of secondary infections. The authors suggest direct physiological pathways from depression to HIV progression and indirect pathways (e.g., behavioral, social, and psychological). In addition to depression, substance use, poor social support, hopelessness, medication nonadherence, and risky sexual behavior seem to be integral in HIV progression. Based on the individual relationships of these variables to depression and HIV progression, a comprehensive multipath model, incorporating all factors, serves to explain how severe emotional distress may lead to accelerated progression to AIDS.

Understanding the influence of depression on self-efficacy, work status and condom use among HIV clients in Uganda

OBJECTIVES

Depression is common among persons living with HIV/AIDS in sub-Saharan Africa, yet few studies in the region have assessed the relationship of depression to economic well-being and risk-reduction behavior. Among HIV clients in Uganda, we examined whether depression is directly related to self-efficacy, work status, and condom use, as well as indirectly through its interaction with physical health functioning.

METHODS

Baseline data from a prospective longitudinal cohort of 602 clients entering HIV care were examined. In separate multivariate analyses, we examined whether depression [both depressive severity and clinical depression, as measured by the nine-item Patient Health Questionnaire (PHQ-9)], physical health functioning, and their interaction were predictors of current work status, consistent condom use, and general self-efficacy, controlling for measures of social support, stigma, and demographics.

RESULTS

Mean PHQ-9 score was 5.2 (S.D.=3.9; range=0-24) and 13% had scores ≥10 (indicator of clinical depression). Not being depressed, better physical health, and their interaction were predictors of working, while lower depressive severity, lower physical health, and their interaction were associated with always using condoms. Better physical health was predictive of greater self-efficacy, but not depression; general self-efficacy was predictive of both work status and condom use.

CONCLUSIONS

Effective diagnosis and treatment of depression may be critical to maximizing the benefits of HIV treatment with regard to both HIV prevention and restoring the social and economic health of persons living with HIV.

Factors associated with condom use among HIV clients in stable relationships with partners at varying risk for HIV in Uganda

In Africa, HIV infections occur mostly in stable relationships, yet little is known about the determinants of condom use in this context. We examined condom use among 272 coupled HIV clients in Uganda who had just screened for ART eligibility; 128 had an HIV-positive partner, 47 HIV-negative, and 97 a partner with unknown HIV status. Sixty-six percent reported unprotected sex with their partner over the past 6 months (57-70% across the three subgroups). Multiple variables among socioeconomic characteristics, physical health, social support, and psychosocial adjustment were correlated with condom use in bivariate analysis, but in multivariate analysis, condom use self-efficacy was the only predictor of condom use in the total sample and subgroups; church attendance and physical functioning were also predictors among unknown status couples. This analysis reveals high rates of unprotected sex among coupled HIV clients, regardless of partner's HIV status, and suggests multiple targets for prevention.

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

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

A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected individuals

OBJECTIVE

To evaluate cognitive-behavioral therapy to enhance medication adherence and reduce depression (CBT-AD) in individuals with HIV.

DESIGN

A two arm, randomized, controlled, cross-over trial comparing CBT-AD to enhanced treatment as usual only (ETAU). ETAU, which both groups received, included a single-session intervention for adherence and a letter to the patient's provider documenting her or his continued depression. The intervention group also received 10 to 12 sessions of CBT-AD.

MAIN OUTCOME MEASURES

Adherence to antiretroviral therapy as assessed by Medication Event Monitoring Systems (MEMs) and depression as assessed by blinded structured evaluation.

RESULTS

At the acute outcome assessment (3-months), those who received CBT-AD evidenced significantly greater improvements in medication adherence and depression relative to the comparison group. Those who were originally assigned to the comparison group who chose to cross over to CBT-AD showed similar improvements in both depression and adherence outcomes. Treatment gains for those in the intervention group were generally maintained at 6- and 12-month follow-up assessments. By the end of the follow-up period, those originally assigned CBT-AD demonstrated improvements in plasma HIV RNA concentrations, though these differences did not emerge before the cross-over, and hence there were not between-groups differences.

CONCLUSIONS

CBT-AD is a potentially efficacious approach for individuals with HIV struggling with depression and adherence. Replication and extension in larger efficacy trials are needed.

Formative study to develop the Eban treatment and comparison interventions for couples

OBJECTIVE

To describe formative and pilot-testing research that generated themes and procedures, curricula, and critical measures for a randomized clinical trial testing a Risk Reduction Intervention for HIV-serodiscordant African American couples (Project Eban).

DESIGN

This article describes the themes that emerged from discussions with African American serodiscordant couples about HIV-related risks from focus groups with 11 couples and pilot study results with 32 couples across 4 sites.

METHODS

In step 1, focus groups examined the need for a Risk Reduction Intervention for HIV-serodiscordant African American couples and confirmed 4 themes that formed the basis for the intervention curriculum and study format. In step 2, a pilot study refined the clinical trial procedures for this population and tested critical measures and selected portions of the curriculum for both the treatment and the comparison interventions.

RESULTS

Based on these findings, stigma and psychological distress, barriers to condom use, insufficient support from community and service organizations, and the lack of skills that emphasize individual and relationship protection were ultimately integrated into the Risk Reduction Intervention.

CONCLUSIONS

Pilot study findings highlighted the importance of examining gender and ethnicity in HIV-impacted couples along with factors that heightened HIV-related risk behaviors that affect couples' skills and psychological adjustment. The goal was to ensure that a skill-based, culturally congruent, relationship-centered intervention could be understood and of interest to couples. Future analyses in the main trial will be discussed.

High levels of risk behavior among people living with HIV Initiating and waiting to start antiretroviral therapy in Cape Town South Africa

Baseline data were collected in Cape Town during 2006 to study if patients on combination antiretroviral therapy (ART) experience decreased inhibition to avoid risky sexual behavior. A total of 924 HIV-positive individuals were recruited; 520 who initiated ART within 3 months and 404 waiting for ART. Nearly half of men (40.1%) and women (46.3%) reported having unprotected sex their last time. Men and women who did not disclose their HIV status to their partner [Odds ration (OR)=2.57 (95% CI: 1.22-5.50) and 2.84 (95% CI: 1.84-4.39), respectively], and those with ambivalent perception about the relationship between ART and HIV transmission [OR=2.08 (95% CI: 1.00-4.30) and 2.39 (95% CI: 1.50-3.84), respectively], were twice as likely to have had unprotected sex their last time. Results suggest an urgent need to strengthen prevention interventions among HIV-positive individuals on and about to start ART in this setting.

Sexual behavior and reproductive health among HIV-infected patients in urban and rural South Africa

BACKGROUND

With the rollout of antiretroviral therapy in South Africa and its potential to prolong the lives of HIV-infected individuals, understanding the sexual behavior of HIV-positive people is essential to curbing secondary HIV transmission.

METHODS

We surveyed 3,819 HIV-positive patients during their first visit to an urban wellness clinic and a rural wellness clinic.

RESULTS

Urban residents were more likely than rural residents to have current regular sex partners (75.1% vs. 46.0%; chi2 odds ratio [OR] = 3.531; P < 0.001), to have any current sexual partners (75.3% vs. 51.2%; chi2 OR = 2.908; P < 0.001), and to report consistent condom use with regular partners (78.4% vs. 48.3%; chi2 OR = 3.886; P < 0.001) and with casual partners (68.6% vs. 48.3%; chi2 OR = 2.337; P < 0.001). In multivariate analysis, independent predictors of consistent condom use with regular partners included across gender, urban residence, and higher education levels; for women, disclosure and younger age; and for men only, no history of alcohol consumption. Male and female participants with a casual sexual partner were less likely to use a condom consistently with regular partners. Additionally, urban residence and a CD4 count greater than 200 cells/mm as well as (for women only) a higher household income and a history of alcohol consumption were predictors of having a regular sexual partner.

CONCLUSIONS

HIV prevention programs in South Africa that emphasize the importance of condom use and disclosure and are tailored to the needs of their attending populations are critical given the potential for HIV-infected individuals to resume risky sexual behavior with improving health.

Does distress tolerance moderate the impact of major life events on psychosocial variables and behaviors important in the management of HIV?

Living with HIV involves management of multiple stressful disease-related and other life events. Distress tolerance may provide a functional, individual-based context for qualifying the established relationships between major life events and psychosocial variables important in the management of HIV. The present study provided a preliminary test of the hypothesis that distress tolerance moderates the impact of major life events on these predictors of disease progression. HIV-positive patients (n=116) completed psychosocial and medical questionnaires. Results indicated that major life events interacted with distress tolerance such that lower distress tolerance and higher life events were associated with significantly higher levels of depressive symptoms, substance use coping, alcohol and cocaine use, and medication adherence. In addition, distress tolerance was directly related to self-reported HIV-related symptoms. These results suggest that low distress tolerance, particularly in the face of major life events, may present significant challenges to adaptive management of HIV. Distress tolerance assessment may help to specify targets for cognitive-behavioral and stress management treatments for people living with HIV.

Behavioral aspects of HIV care: adherence, depression, substance use, and HIV-transmission behaviors

A variety of psychosocial stressors are involved in living with HIV, maintaining a regimen of highly active antiretroviral therapy, and negotiating necessary self-care behaviors. Because health care providers are in regular contact with HIV-infected individuals in care, these contacts allow for the opportunity to assess and intervene on important variables related to quality of life and HIV outcomes. This article reviews information about four important behavioral aspects of HIV care: treatment adherence, depression, high-risk sex, and substance abuse. Efforts by health care providers to address these factors may result in better treatment outcomes, enhanced quality of life among HIV patients, and decreased HIV transmission.

Determinants of unprotected sex among HIV-positive patients in South Africa

This study examined the prevalence of unprotected sex, other sexual risk behaviours, and factors associated with unprotected sex among men and women recently diagnosed with HIV in South Africa. One hundred and forty-nine outpatients (44 males and 105 females) were assessed, of whom 101 were sexually active at least 6 months prior to study entry. Subjects were asked about sexual risk behaviours with reference to their most recent sexual encounter. Logistic regression analysis was employed to determine the predictors of condom use, with independent variables selected from five general categories: (1) sociodemographic characteristics; (2) situational characteristics regarding sexual intercourse (i.e. alcohol or drugs used before intercourse); (3) clinical diagnoses; (4) negative life events; and (5) coping styles. Fifty-five patients (19 males and 36 females), representing 54.4% of those sexually active in the 6 months preceding the study, had not used a condom during the most recent intercourse. Compared with those who used condoms, participants who did not significantly reported shorter duration of HIV infection (t = -2.7, p < 0.001), have a current partner (chi2 = 3.98, p = 0.005), and lack knowledge of their partner's HIV status (chi2 = 4.78, p = 0.004). Also they were significantly more likely to engage in denial (t = 3.2, p < 0.002) and to use substances (t = 1.98, p < 0.05) as a means of coping. Logistic regression showed that shorter duration of illness (odds ratio (OR) = 1.2, 95% confidence interval (CI) = 1.01-1.41) and coping styles characterized by denial (OR = 0.6, 95% CI = 0.45-0.96) were significantly associated with unprotected sex. These data suggest the need for interventions to further reduce sexual risk behaviours in HIV-positive patients in South Africa.

Risk behaviors of youth living with HIV: pre- and post-HAART

OBJECTIVE

To examine the transmission behavior among youth living with HIV (YLH), pre- and post-HAART.

METHODS

Two cohorts were recruited: (1) 349 YLH during 1994 to 1996 and (2) 175 YLH during 1999 to 2000, after the wide availability of HAART. Differences in sexual and substance-use risk acts and quality of life were examined.

RESULTS

Post-HAART YLH were more likely to engage in unprotected sex and substance use, to be more emotionally distressed, and to have lower quality of life than were pre-HAART YLH.

CONCLUSIONS

Targeted interventions for YLH that address reductions in transmission acts and aim to improve quality of life are still needed.

Reasons for unsafe sex among a community sample of people with HIV/AIDS

In a sample of 117 HIV positive men and women, 34 (29%) were identified as engaging in risky sexual behavior in the past six months and were asked for reasons they did so. Analysis using broad categories revealed that partner-related reasons and hedonistic reasons were the most frequent reasons overall (71%). More male (87%) than female (60%) responses were captured by those two categories. Differences by partner status, viral load and age were not as pronounced. Specific interventions and intervention frameworks are suggested.

Mental health concerns of HIV-infected gay and bisexual men seeking mental health services: an observational study

Addressing mental health concerns of HIV-positive individuals is an important component of providing quality HIV care. Mental health intake information from patients with HIV can be an important source of data to complement existing research on HIV and mental health because the intake information contains concerns that are both from the perspective of the patients and are significant enough to bring them into treatment. The current study describes the mental health intake information of HIV-positive men who have sex with men (MSM) at an urban community health clinic over a 1-year period. This information included presenting problems, current symptoms from a symptom checklist, ratings of impairments in functioning, and client histories (e.g., substance abuse, emotional, physical, and sexual abuse, previous treatment). It also included clinicians' Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnoses of the participants, and recommended treatments. Depression was the most prevalent presenting problem (58.1% of clients), followed by anxiety (38.2%). Consistently, depression (96.3%) and low energy (78.2%) were the most frequently endorsed symptoms on a symptom checklist, followed by anxiety (69.2%). HIV-specific problems also played a large role both directly, as a presenting problem, and indirectly as they related to such concerns as relationship issues. Axis I diagnoses included adjustment disorders (50.0%), major depressive disorder (21.4%), and dysthymia (a less severe but more chronic depression) (8.9%). This review highlights the mental health issues that HIV-positive MSM feel are significant enough to require treatment. Because mental health is a key component of overall quality of life, HIV providers who work with MSM can use these data to increase awareness of the types of mental concerns that are most distressing to this population.

Sexual risk reduction among HIV-positive drug-using men who have sex with men

According to the US Centers for Disease Control, the majority of new HIV infections are the direct result of unprotected sexual relations between serodiscordant individuals. Thus, the development of behavioral interventions to increase the safer sex practices of HIV-positive individuals has the potential to reduce the number of new infections. Currently, less than 1% of the total US population is infected with HIV. Targeting behavioral interventions to this smaller group of HIV-positive individuals has the potential for making cost-effective reductions in the number of new infections. Despite reports that some HIV-positive individuals continue to engage in high-risk behaviors, interventions designed to prevent secondary transmission of HIV are rare. In this era of highly active antiretroviral therapy (HAART), interventions for HIV-positive individuals are more critical than ever to address the unique challenges and issues they face regarding disclosure and partner notification, use of HAART and sexual risk behavior, and HIV-related stigma. Although a growing number of reports document the efficacy of sexual risk reduction interventions for HIV-positive individuals, to date none of these studies have focused on drug-using populations. This article focuses on sexual risk reduction interventions for HIV-positive men who have sex with men (MSM), the largest group of HIV-positive individuals in the United States. It reviews factors associated with high-risk behaviors and discusses some findings from research with HIV-positive methamphetamine users, including (1) data from a small qualitative study and its implications for the development of new interventions, and (2) baseline data from an ongoing large-scale study of the efficacy of a theory-based sexual risk reduction intervention for HIV-positive methamphetamine-using MSM. The article concludes with a discussion of future research issues, including, for example: Can sexual risks be reduced in the context of active drug use? Are different patterns of drug use, or specific drugs, associated with increased risk behavior? How do gender, race, and culture relate to the efficacy of specific interventions?

Sensation seeking and alcohol use as markers of sexual transmission risk behavior in HIV-positive men

Alcohol use and sensation-seeking personality characteristics are commonly associated with sexual risk behavior in populations at risk for HIV infection. However, these associations are not well understood and have not yet been examined in people living with HIV-AIDS. We used path analyses to test a model of sensation seeking, alcohol use expectancies, and sexual risk behaviors among 197 HIV seropositive men. Results showed that alcohol use outcome expectancies and alcohol used in sexual contexts were closely associated with unprotected intercourse and that sensation seeking was significantly related to alcohol use expectancies. Sensation seeking did not mediate the association between alcohol use and unprotected sexual behavior. Further analyses showed that the association between sensation seeking and alcohol use in unprotected sexual contexts was accounted for by expectancies that alcohol use improves sexual performance and enhances sexual pleasure. Analyses also indicated that men living with HIV-AIDS who used alcohol in sexual contexts were characterized by greater overall frequency and quantity of drinking. Prevention interventions may be improved by tailoring them for alcohol-using HIV-infected men, particularly by challenging beliefs and expectations that alcohol enhances sexual performance and sexual pleasure.

The relationship of unsafe sexual behavior and the characteristics of sexual partners of HIV infected and HIV uninfected adolescent females

PURPOSE

To compare characteristics of sexual relationships in HIV infected and HIV uninfected female adolescents and their association with condom use.

METHODS

HIV infected and uninfected subjects, aged 13-19 years, were enrolled in a prospective HIV study from 15 sites in 13 U.S. cities. Baseline data on demographic information, substance use, sexual behavior, partner information, and condom use were collected through direct and computer-assisted interviews from currently sexually active females. Univariate, multiple logistic regression, and repeated measures analyses were employed.

RESULTS

Data from 153 HIV infected and 90 HIV uninfected female subjects showed, on average, that current partners were 4-6 years older. In multivariate analysis, HIV infected subjects were older (OR = 1.37; 95% CI: 1.04-1.81), had more lifetime partners (OR = 2.23; 95% CI: 1.03-4.82), initiated consensual vaginal sex earlier (OR = .74; 95% CI:.58-.95), perceived partner to also be HIV infected (OR = 7.46; 95% CI: 3.2-17.4), and had less unprotected sex (OR = .27; 95% CI:.16-.45). Length of relationship was associated with more unprotected sex for both HIV infected and uninfected subjects (OR = 2.59, 95% CI: 1.27-5.27, OR = 4.13; 95% CI: 1.31-13.05, respectively). Mean partner age difference was greater among HIV infected than for HIV uninfected (OR = 1.06; 95%CI: 1.01-1.12); this greater age difference for HIV infected females was associated with less protection (OR = 1.09; 95% CI: 1.03-1.15). HIV disclosure influenced condom use: without disclosure, less condom use was reported (OR = 6.8; 95% CI: 2.29-20.24) controlling for perception that partner was also HIV infected (OR = 1.1; 95% CI: 1.02-1.21).

CONCLUSIONS

Because age differential influenced reported condom use, more research, particularly qualitative, is needed into the dynamics of these relationships. Prevention efforts must address partners, particularly older ones.

Are negative affective states associated with HIV sexual risk behaviors? A meta-analytic review

This meta-analytic review examined whether negative affective states (depressive symptomatology, anxiety, anger) are associated with sexual behaviors that place people at risk for contracting or transmitting HIV. The results from 34 study samples were included in the analysis. Contrary to popular belief, the findings as a whole provide little evidence that negative affect is associated with increased sexual risk behavior. The average weighted correlation for the overall association was .05. The effect size was nonsignificantly higher for anger (r = .10) than for depressive symptoms (r = .04) or anxiety (r = .03). The variability of effect sizes was not accounted for by type of sexual risk measure, subject population, or methodological aspects of the studies. Conceptual and methodological limitations of the literature are identified and directions for future research are discussed.

The additional value of anticipated regret and psychopathology in explaining intended condom use among drug users

Abstract In this study we examine determinants of intended condom use with casual and steady sex partners among drug users. Our aim was to find out whether anticipated regret and psychopathology represent additional factors in explaining condom use behaviour, on top of the constructs defined in traditional psychosocial models of behaviour. A questionnaire measuring intentions, attitude, beliefs, personal norm, subjective norm, descriptive norm, self-efficacy and anticipated regret toward condom use with steady and casual sex partners, and the Symptom Checklist '90 (to measure dimensions of psychopathology) were handed out to 150 Dutch drug users. The results showed that intended condom use with steady sex partners was mainly predicted by self-efficacy, personal norm and anticipated regret (total R2 = 0.41). Lower feelings of hostility and a more positive personal norm, subjective norm and attitude significantly predicted intended condom use with casual sex partners (total R2 = 0.24). The results also showed that intended condom use with steady sex partners seems to result from anticipating possible barriers, whereas condom use with casual sex partners is largely a matter of having safe sex norms. Practical implications of this study for Aids-preventive campaigns are also discussed.

Condom effectiveness in reducing heterosexual HIV transmission

BACKGROUND

The amount of protection that condoms provide for HIV and other sexually transmitted diseases is unknown. Cohort studies of sexually active HIV serodiscordant couples with follow-up of the seronegative partner, provide a situation in which a seronegative partner has known exposure to the disease and disease incidence can be estimated. When some individuals use condoms and some do not, namely some individuals use condoms 100% of the time and some never use (0%) condoms, condom effectiveness can be estimated by comparing the two incidence rates. Condom effectiveness is the proportionate reduction in disease due to the use of condoms.

OBJECTIVES

The objective of this review is to estimate condom effectiveness in reducing heterosexual transmission of HIV.

SEARCH STRATEGY

Studies were located using electronic databases (AIDSLINE, CINAHL, Embase, and MEDLINE) and handsearched reference lists.

SELECTION CRITERIA

For inclusion, studies had to have: (1) data concerning sexually active HIV serodiscordant heterosexual couples, (2) a longitudinal study design, (3) HIV status determined by serology, and (4) contain condom usage information on a cohort of always (100%) or never (0%) condom users.

DATA COLLECTION AND ANALYSIS

Studies identified through the above search strategy that met the inclusion criteria were reviewed for inclusion in the analysis. Sample sizes, number of seroconversions, and the person-years of disease-free exposure time were recorded for each cohort. If available, the direction of transmission in the cohort (male-to-female, female-to-male), date of study enrollment, source of infection in the index case, and the presence of STDs was recorded. Duplicate reports on the same cohort and studies with incomplete or nonsepecific information were excluded. HIV incidence was estimated from the cohorts of "always" users and for the cohorts of "never" users. Effectiveness was estimated from these two incidence estimates.

MAIN RESULTS

Of the 4709 references that were initially identified, 14 were included in the final analysis. There were 13 cohorts of "always" users that yielded an homogeneous HIV incidence estimate of 1.14 [95% C.I.:.56, 2.04] per 100 person-years. There were 10 cohorts of "never" users that appeared to be heterogeneous. The studies with the longest follow-up time, consisting mainly of studies of partners of hemophiliac and transfusion patients, yielded an HIV incidence estimate of 5.75 [95% C.I.: 3.16, 9.66] per 100 person-years. Overall effectiveness, the proportionate reduction in HIV seroconversion with condom use, is approximately 80%.

REVIEWER'S CONCLUSIONS

This review indicates that consistent use of condoms results in 80% reduction in HIV incidence. Consistent use is defined as using a condom for all acts of penetrative vaginal intercourse. Because the studies used in this review did not report on the "correctness" of use, namely whether condoms were used correctly and perfectly for each and every act of intercourse, effectiveness and not efficacy is estimated. Also, this estimate refers in general to the male condom and not specifically to the latex condom, since studies also tended not to specify the type of condom that was used. Thus, condom effectiveness is similar to, although lower than, that for contraception.

Application of the theory of gender and power to examine HIV-related exposures, risk factors, and effective interventions for women

Developed by Robert Connell, the theory of gender and power is a social structural theory based on existing philosophical writings of sexual inequality and gender and power imbalance. According to the theory of gender and power, there are three major social structures that characterize the gendered relationships between men and women: the sexual division of labor, the sexual division of power, and the structure of cathexis. The aim of this article is to apply an extended version of the theory of gender and power to examine the exposures, social/behavioral risk factors, and biological properties that increase women's vulnerability for acquiring HIV. Subsequently, the authors review several public health level HIV interventions aimed at reducing women's HIV risk. Employing the theory of gender and power among women marshals new kinds of data, asks new and broader questions with regard to women and their risk of HIV, and, most important, creates new options for prevention.

Risk behaviors related to heterosexual transmission from HIV-infected persons. Supplement to HIV/AIDS Surveillance Study Group

BACKGROUND

To monitor heterosexually acquired HIV infection, it is important to understand transmission from persons infected with HIV to their sex partners.

GOAL

To describe sexual behaviors of persons infected with HIV that are related to transmission.

STUDY DESIGN

Cross-sectional interviews were conducted from January 1995 to December 1998.

RESULTS

Of 4743 heterosexual respondents who had known about their HIV infection for 1 year or longer, 42% were not sexually active and 13% had one sex partner with HIV; the remaining 2099 comprised the sample for analysis. Most respondents were male, black, and of low socioeconomic status. Approximately 60% reported one or more sexual risk behavior. Steady partner's HIV status was the strongest predictor in most models for risk behaviors; those with a partner who was not infected were significantly less likely than those with an infected partner to report any sexual transmission risk behavior (P < 0.05).

CONCLUSIONS

The findings point to a continued need to focus on behavioral prevention measures that reduce the heterosexual transmission of HIV.

Psychological and social correlates of high-risk sexual behaviour among men and women living with HIV/AIDS

Men and women living with HIV/AIDS who experience difficulty maintaining safer sex practices place their sex partners as well as themselves at considerable risk for sexually transmitted infections. Psychological correlates of continued sexual risk behaviours provide important information for intervention development. Continued sexual risk behaviour was investigated in a sample of 203 HIV-positive men and 129 HIV-positive women recruited from infectious disease clinics and AIDS service agencies. The study showed that 42% of men and 42% of women reported at least one occasion of unprotected anal or vaginal intercourse in the preceding six months. Unprotected intercourse frequently occurred outside of long-term relationships and with partners who were not known to be HIV-infected. Similar to populations at primary risk, HIV-infected men and women reported alcohol and drug use, including use before sexual episodes. However, the association between substance use and unprotected sex was modest for men and absent for women. Contrary to previous research, emotional distress and maladaptive coping were not related to continued sexual risk. Interventions are urgently needed to support men and women living with HIV/AIDS in maintaining long-term safer sex practices.

Targeted prevention for people with HIV/AIDS: feasible and desirable?

People with HIV/AIDS are rarely chosen as a target group for prevention activities. In this paper we look at empirical and theoretical evidence for the feasibility and desirability of directing preventive interventions at HIV-positives. Research data on the behaviour and motivation of HIV-positives suggests that the differences between HIV-positives and HIV-negatives and those who are unaware of their HIV-status are not large. However, specific determinants of behaviour, such as responsibility for others or the risk of superinfection, have seldom been measured. Effective interventions targeting at HIV-positives and focussing on prevention are lacking. Fear of increased stigmatization has been used as an argument against focussing prevention activities at HIV-positives. Theoretically that argument is probably not correct: positive coping with HIV may invite positive reactions. The conclusion is that HIV-positives should be chosen as a special target group for additional planned preventive interventions. Because people need to be aware of their HIV status, testing and treatment sites are adequate settings. Effective interventions should be developed on the basis of theory and evidence about the specific determinants of risk behaviour of HIV-positives: protecting oneself for superinfection and protecting one's partner.

Medical use of recreational drugs by AIDS patients

A survey of 72 patients at an AIDS clinic regarding self-medication with recreational drugs for medical or psychological conditions related to their illness disclosed that marijuana was the primary drug used. The perceived benefit was for gastrointestinal conditions such as nausea, vomiting, indigestion and appetite improvement. Use of other "recreational" drugs as self-medication was reported to usually be ineffective or to worsen the condition they sought to help. Fifty-eight percent of patients reported some attempt to self-medicate. Thirty-two percent were currently using marijuana, and most admitted to pre-AIDS marijuana use. Fifty-seven percent of the sample reported some pre-AIDS drug use, primarily alcohol and marijuana. Results are discussed in terms of potential clinical problems arising from continued recreational drug use among AIDS patients.

Incidence of three sexually transmitted diseases during a safer sex promotion program for HIV-infected women

Promotion of safer sex practices typically includes education, skills building, and condom distribution. To evaluate the impact of such promotions and describe risk factors for sexually transmitted disease (STD), a retrospective review of 741 sexually active HIV-infected women was conducted. The cohort was African-American (82%), at least 22 years of age (81%), acquired HIV through sex (36%), had a CD4 count above 200/ mm3 (76%), and had a history of substance (alcohol or drug) use (38%). Those with incident STD (14.7%) were more likely to be under 22 years of age, to have a history of substance use, and to have an STD at entry. Traditional methods of promoting safer sex practices should be enhanced by other options such as regular screening, partner treatment, and the use of microbicides and other female-controlled methods.

The relationship between risk networks' patterns of crack cocaine and alcohol consumption and HIV-related sexual behaviors among adult injection drug users: a prospective study

Social context may be an important determinant of drug and alcohol consumption and HIV-related behaviors. To assess the influence of peers on drug users' risk behaviors this study examined the association between individual level and group level behaviors. This analysis reports on the prospective association between baseline self-reported drug and alcohol use of the network members of injection drug users, and self-reported sexual behaviors and alcohol use at 5-month follow-up. Participants were a nontreatment sample of inner-city injection drug users who volunteered for a network-oriented HIV preventive intervention. They were predominantly unemployed, African American males. Of the 71 index participants who completed both the baseline and follow-up interviews, 227 of their drug network members were enrolled in the study. At baseline indexes' sexual risk behaviors were significantly associated with their drug network members' level of crack cocaine use. At follow-up higher levels of alcohol and crack use among drug network members were associated with indexes' reports of multiple sex partners and increased alcohol consumption. Higher levels of crack use among the drug network members were associated with the indexes' reporting casual sex partners at follow-up. These results highlight the importance of studying the role of peer group influence and the social context of risk behaviors.

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

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

Micronutrient profiles in HIV-1-infected heterosexual adults

There is compelling evidence that micronutrients can profoundly affect immunity. We surveyed vitamin supplement use and circulating concentrations of 22 nutrients and glutathione in 64 HIV-1 seropositive men and women and 33 seronegative controls participating in a study of heterosexual HIV-1 transmission. We assayed antioxidants (vitamins A, C, and E; total carotenes), vitamins B6 and B12, folate, thiamin, niacin, biotin, riboflavin, pantothenic acid, free and total choline and carnitine, biopterin, inositol, copper, zinc, selenium, and magnesium. HIV-infected patients had lower mean circulating concentrations of magnesium (p < 0.0001), total carotenes (p = 0.009), total choline (p = 0.002), and glutathione (p = 0.045), and higher concentrations of niacin (p < 0.0001) than controls. Fifty-nine percent of HIV+ patients had low concentrations of magnesium, compared with 9% of controls (p < 0.0001). These abnormal concentrations were unrelated to stage of disease. Participants who took vitamin supplements had consistently fewer low concentrations of antioxidants, across HIV infection status and disease stage strata (p = 0.0006). Nevertheless, 29% of the HIV+ patients taking supplemental vitamins had subnormal levels of one or more antioxidants. The frequent occurrence of abnormal micronutrient nutriture, as found in these HIV+ subjects, may contribute to disease pathogenesis. The low magnesium concentrations may be particularly relevant to HIV-related symptoms of fatigue, lethargy, and impaired mentation.

Human immunodeficiency virus-type 1 infection in an inner-city alcohol treatment program

The human immunodeficiency virus (HIV) infection rate was examined in a selected cohort of healthy clients of an inner-city alcohol treatment center from 1990 through 1993. These subjects were also participating in a research protocol (n = 258) designed to assess immunity and HIV risk behaviors in inner city alcohol-dependent persons. Healthy alcohol-abusing heterosexual clients (165) had HIV testing conducted in an inner-city ambulatory alcohol treatment center between September 1990 and December 1993. Respondents were 93.9% African-American and 3.6% Hispanic; 72.1% were male. Anonymous HIV-1 antibody testing was conducted retrospectively for an additional 80 subjects who participated in the research protocol during the same interval, but for whom HIV-1 antibody testing was not conducted clinically at the time. HIV infection rate among the clinic-tested subjects (n = 165) was 4.4% for individuals who were exclusively alcohol-dependent, 1.4% for non-injecting drug use (IDU) mixed substance abusers, and 46.8% for clients with a history of IDU. Rates did not differ among cohorts tested in different years. Among non-injecting drug users tested in the clinic, all infected respondents (n = 3) were women (p = 0.03). Among those tested anonymously (n = 80), however, infection rate for exclusively alcohol-dependent persons was 16.7%, non-IDU mixed abusers 11.1%, and injecting drug users 48.3%, with seropositive males as well as females in each group. HIV infection rates for the pooled samples (n = 245) were 8.7% for exclusively alcohol-dependent persons, 5.1% for mixed abusers, and 54.5% for injecting drug users. Among non-injecting drug users, exclusively alcohol-dependent women had a significantly higher (p < 0.01) infection rate (20.0%) than the remaining females and males. Infection rates among exclusively alcohol-dependent males, male and female polysubstance non-IDU abusers, and injecting drug users were comparable with that seen in an earlier screening in the same clinic in 1989, with apparently little diffusion of infection from the IDU population to other substance abusers. An exception seemed to be exclusively alcohol-dependent females, who show substantially elevated rates. Age, housing, and other social differences may help segregated substance-abusing populations in the relatively small Newark metropolitan area, although not protecting exclusively alcohol-dependent females.