Cumulative exposure to stimulants and immune function outcomes among HIV-positive and HIV-negative men in the Multicenter AIDS Cohort Study.

We examined associations between stimulant use (methamphetamine and cocaine) and other substances (nicotine, marijuana, alcohol and inhaled nitrites) with immune function biomarkers among HIV-seropositive (HIV +) men taking highly active antiretroviral therapy (ART) and HIV-seronegative (HIV-) men in the Multicenter AIDS Cohort Study. Among HIV + men, cumulative adherence to ART (4.07, 95% confidence interval [CI]: 3.52, 4.71, per 10 years of adherent ART use), and recent cohort enrolment (1.38; 95% CI: 1.24, 1.55) were multiplicatively associated with increase in CD4+/CD8+ ratios. Cumulative use of methamphetamine (0.93; 95% CI: 0.88, 0.98, per 10 use-years), cocaine (0.93; 95% CI: 0.89, 0.96, per 10 use-years) and cumulative medical visits (0.99; 95% CI: 0.98, 0.99, per 10 visit-years), each showed small negative associations with CD4+/CD8+ ratios. Among HIV- men, cumulative medical visits (0.996; 95% CI: 0.993, 0.999), cumulative number of male sexual partners (0.999; 95% CI: 0.998, 0.9998, per 10 partner-years) and cigarette pack-years (1.10; 95% CI: 1.02, 1.18, per 10 pack-years) were associated with CD4+/CD8+ ratios over the same period. ART adherence is associated with a positive immune function independent of stimulant use, underscoring the influence of ART on immune health for HIV+ men who engage in stimulant use.

Expectancies of sexual "escape" and sexual risk among drug and alcohol-involved gay and bisexual men.

PURPOSE: We tested the hypotheses that sexual risk would relate to gay/bisexual men's patterns of combining alcohol or drugs with sex, their motivation to use drugs to cognitively "escape" awareness of HIV risk, and their use of bars as social and sexual settings. METHODS: We conducted extensive interviews among African-American (n = 139) and White (n = 112) gay and bisexual men who were attending a behavioral intervention for safer sex results. Those who frequently combined drugs with sex reported higher rates of sexual risk and Hepatitis B infection than did men who infrequently combined substances with sex, or who combined only alcohol with sex. Sexual risk was pronounced among more frequent drug users who also reported strong expectancies that alcohol or drugs facilitate sex and cognitively escape from awareness of HIV risk. Frequenting bars per se was not an important factor in sexual risk. IMPLICATIONS: Men who use alcohol or drugs to enhance sexuality and escape self-awareness of HIV risk have a significantly diminished capacity to avoid sexual risk.

Impact of combination therapies on HIV risk perceptions and sexual risk among HIV-positive and HIV-negative gay and bisexual men.

The availability of improved HIV treatments may prompt reduced concern about HIV and sexual risk. Gay and bisexual men (N = 554, 17% HIV-positive) completed measures of treatment attitudes, sexual risk, and assumptions regarding the infectiousness of sexual partners. A substantial minority reported reduced HIV concern related to treatment advances. Reduced HIV concern was an independent predictor of sexual risk, particularly among HIV-positive men. In response to hypothetical scenarios describing sex with an HIV-positive partner, participants rated the risk of unprotected sex to be lower if the partner was taking combination treatments and had an undetectable viral load, relative to scenarios with a seropositive partner not taking combination treatments. Prevention efforts must address attitudinal shifts prompted by recent treatment successes, stressing the continued importance of safer sex, and that an undetectable viral load does not eliminate infection risks.

Sex, drugs and escape: a psychological model of HIV-risk sexual behaviours.

The lack of an effective HIV vaccine or other biomedical intervention means that behavioural change will continue to be critical to the prevention of HIV infection. Despite near universal knowledge of HIV and sexual safety, and widespread intentions to be safe, rates of unprotected sex and HIV sero-conversion remain high among gay and bisexual men. Explanatory models that link risk-taking and prevention to rational processes such as knowledge, social norms, behavioural intentions, or perceived vulnerability to infection, cannot fully account for the continued risk behaviours observed in virtually all cohorts of gay men. We feel that innovative conceptions of risk and risk prevention are needed, that emphasize non-rational, affective processes in risk-taking and decision-making. Consistent with recent models from social psychology, we propose that for many people sexual risk does not stem from a lack of community norms or personal standards, but from a desire to escape cognitive awareness of very rigorous norms and standards. Being self-aware of HIV risk arouses anxiety and precludes highly-desired activities: fatigue, fatalism, or other negative affect over HIV may lead people to 'cognitively disengage' within the sexual situation, and not to follow their norms or intentions toward safety. We propose that both substance use and the approach of high stimulation or other sexual settings facilitates this cognitive disengagement, wherein people enact 'automatic' sexual scripts and/or become more responsive to external pressures toward risk. We briefly review current psychosocial models of HIV risk behaviour, outline a cognitive escape model with particular emphasis on substance use as a behavioural risk factor, and discuss implications of an escape model for behavioural interventions among gay and bisexual men.

Sexual adventurism, high-risk behavior, and human immunodeficiency virus-1 seroconversion among the Chicago MACS-CCS cohort, 1984 to 1992. A case-control study.

BACKGROUND AND OBJECTIVES: To predict incident human immunodeficiency virus (HIV)-1 seroconversions among a cohort of gay and bisexual men based on recalled sexual behavior, drug use, partnership status, and an index of sexual adventurism/risk-seeking attitudes. STUDY DESIGN: A nested case-control design was used in a retrospective study spanning a 9-year period. RESULTS: Sexual adventurism was an important predictor of HIV-1 infection. The partial risk ratio for our 100-point adventurism scale indicated a marginal rate of increase in seroconversion risk of 4% (odds ratio = 1.04; 95% confidence interval = 1.02 to 1.06), with almost 79% of seroconverters scoring above the median on the index. As expected, partner status, drug use, and unprotected receptive anal (RA) intercourse were associated with seroconversion. However, multivariate results indicated that men using condoms consistently in RA sex were also at higher risk for infection (odds ratio = 2.68; 95% confidence interval = 1.04 to 6.95) than men who abstained from RA intercourse. CONCLUSIONS: Results are discussed with respect to their implications for HIV prevention intervention and research. Recommendations include the development of new approaches and the adaptation of existing intervention techniques that recognize and treat persons with strong risk-taking predispositions.

Substance use, HIV, and gay men.

AIDS: Recreational drug use is linked to infectious disease transmission among gay men. A review of the literature on substance use and sexual behavior divided the research into three categories: studies that relate sexual behavior to global measures of drug use; studies that look within groups of gay men at drug use behavior in the sexual context; and studies that look at sexual episodes among individual cases to determine whether the use of specific drugs lead to specific sexual activities. The evidence for a direct association between substance use and increased risk of HIV infection among susceptible gay men is incontrovertible. Simple associational models demonstrate the ways in which the pairing of sex and drug use create a learned association between these activities. The drug-sex relationship may also be mediated by personality characteristics, such as sensation-seeking. Interventions targeting gay men must combine community interventions and individual or small group intervention approaches.^ieng

A case-control study of human immunodeficiency virus type 1 seroconversion and risk-related behaviors in the Chicago MACS/CCS Cohort, 1984-1992. Multicenter AIDS Cohort Study. Coping and Change Study.

This paper focuses on 76 human immunodeficiency virus type 1 (HIV-1) seroconverters who concurrently participated in the Chicago, Illinois, component of the Multicenter AIDS Cohort Study (MACS) and the Coping and Change Study (CCS) of homosexual/bisexual men between 1984 and 1992. A nested case-control analysis was performed to assess the critical behavioral risk factors associated with incident HIV-1 infection and the consistency of these relations in early (1984-1988) versus later (1989-1992) phases of the study. Univariate results revealed strong early period associations between seroconversion and various measures of receptive anal intercourse (RAI) that became considerably weaker in the study's later period. The weaker associations reflected the overall decline in levels of RAI among the cohort during the 9 years of observation. In contrast, univariate results revealed stronger later period associations between seroconversion and measures of receptive oral intercourse and insertive anal intercourse. Subsequent multivariate testing did not support the hypothesis that receptive oral intercourse and/or insertive anal intercourse have replaced unprotected RAI as important risk behaviours in the homosexual transmission of HIV-1. In conditional logistic regression models combining intercourse measures with indices of drug and condom use, only the latter variables were consistently associated with HIV-1 seroconversion in both early and later study periods. Adjusted odds ratios (ORs) for nonuse of condoms during RAI were consistently significant throughout the study (ORs = 3.7-4.8), while adjusted odds ratios for recreational drug use variables rose dramatically during the latter half of the study (e.g., for use of cocaine, OR = 81.3 (95% confidence interval 8-824) [corrected], and for use of nitrite "poppers," OR = 9.1 (95% confidence interval 1.8-45.5)). The behavioral intervention applications of these findings, as well as their relation to data from other recent cohort studies of HIV-1 seroconversion among homosexual/bisexual men, are discussed.

Perceptions of social support and psychological adaptation to sexually acquired HIV among white and African American men.

Although the research literature documents the impact of social support on the mental health of people with human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), the assumption that relationships between social support and mental health functioning are comparable across ethnically distinct populations with HIV/AIDS has been challenged. This study reports preliminary data on the relationship between perceptions of social support and mental health in a sample of African American and white men with sexually acquired HIV. Data from 33 respondents revealed considerable differences within the sample. Data from white men revealed strong positive relationships between mental health measures and social support from friends and family, whereas data from African American men revealed negative relationships. Further, measures of social support seem to adequately reflect the support systems of white men but not those of African American men. Implications of these and additional findings for research and practice are considered.

Sexual behavior research on a cohort of gay men, 1984-1990: can we predict how men will respond to interventions?

In 1984, over 1000 gay and bisexual men volunteered to participate in both the Chicago Multicenter AIDS Cohort Study (MACS) and a companion psychosocial study, the Coping and Change Study (CCS). Participants in the semiannual Chicago MACS/CCS evaluations comprise the largest cohort of high-risk men under continuous medical, behavioral, and psychosocial observation. Chicago MACS/CCS researchers prospectively chart the sexual behavior change patterns of the cohort and relate those behavioral changes to psychosocial correlates and actual HIV infection risk. This report summarizes the behavioral natural history of the Chicago MACS/CCS cohort from 1984 to 1990, focusing on receptive anal sex practices and use patterns for alcohol and the most frequently used recreational drugs. As these are prospective observational and not controlled intervention studies, psychosocial correlates of sexual behavior change by members of the cohort are suggestive of factors influencing behavior change rather than indicative of causal relationships. However, the voluntary availability to participants in the Chicago MACS/CCS of HIV-1 antibody test results beginning in late 1985 provided the opportunity to examine whether demographic, psychosocial, or behavioral factors were indicators of sexual behavior change following disclosure and counseling about HIV-1 serostatus. Recommendations for promotion and maintenance of safer sexual behavior for the long run, and limitations in the generalizability of these findings to the much more diverse populations of men who have sex with other men conclude this article.

Substance abuse and HIV infection.

This article reviews what is known about the relationships between recreational psychoactive substance use and HIV infection and sexual behaviors that can transmit HIV. The focus of this article is on nonparenterally used recreational substances and their relationship to HIV transmission behaviors, specifically high-risk sexual behaviors of one of the largest groups of persons at risk for infection--self-identified gay and bisexual men. Published and unpublished studies in this area are reviewed in terms of a hierarchy of epidemiologic evidence that ranges from global associations between substance use and high-risk sexual behaviors to prospective studies of substance use in the context of sexual encounters and incident rates of HIV infection. This article also discusses the secondary community impact of these associations and their intervention implications.

The effects of social support on Hopkins Symptom Checklist-assessed depression and distress in a cohort of human immunodeficiency virus-positive and -negative gay men. A longitudinal study at six time points.

Questionnaire data were collected from a panel of 342 gay men at risk for acquired immune deficiency syndrome enrolled in the Coping and Change Study between 1985 and 1987, and 1988 and 1990. Data were obtained across a period of 5 years in six serial wave pairs to determine the relationship of social support to Hopkins Symptom Checklist-assessed subsequent depression and general distress and to investigate whether the trends observed were stable or transient over time. Both objective and subjective components of social support demonstrated dramatic within-person stability over time (r = .47 to .86). A measure of subjective social support was modestly but significantly associated with lower depression at four of the six time periods and a lower level of general distress at one time period. Before appropriately controlling for current depression, subjective social support appeared to account for up to a third of the variance in future depression; after such controls were included in the regression equation, it became apparent that the independent contribution of support only ranged from 4% to 6% across the study period. This emphasizes the importance of including current mental health in longitudinal analyses. The respondents' social participation and involvement with others did not affect either depression or general distress at any time during the study period. These results indicate that while social participation may have no effect, subjective social support appears to influence often mental health in this cohort. Furthermore, human immunodeficiency virus seropositive men may at times benefit from such support.

Predictors of sexual behavior change among men requesting their HIV-1 antibody status: the Chicago MACS/CCS cohort of homosexual/bisexual men, 1985-1986.

It has been proposed that human immunodeficiency virus (HIV) antibody testing and counseling are effective means of altering sexual behavior among individuals at risk of HIV infection and transmission. However, the evidence supporting this hypothesis is inconclusive. This study examines the factors associated with sexual behavior change among a group of participants in the Chicago MACS/Coping and Change Study (CMACS/CCS) who requested their HIV antibody status when they were first given the opportunity, between 1985 and 1986. A set of demographic and psychosocial predictors were tested in association with 4 possible outcome patterns of sexual behavior change during the time of antibody status disclosure. For comparative purposes, a randomly selected sample of men who did not request disclosure of their HIV antibody status was analyzed. The results revealed that, among the 177 individuals who requested disclosure, the group experiencing an adverse sexual behavior change (i.e., from low risk before disclosure to high risk after disclosure) reported, before disclosure, the highest level of mental distress and denial-fatalism coping strategies and had the lowest levels of social support compared with other groups being analyzed. The psychosocial predictor most strongly associated with adverse sexual behavior change appears to be the use of denial-fatalism coping. Such an association was not found among the nondisclosed comparison group. These results suggest that a subgroup of at-risk, well-educated, white men, with overall high knowledge of HIV transmission, may not benefit from current HIV counseling and testing. Such men at risk for adverse behavioral outcomes might be identified in advance of HIV-1 antibody testing by their psychosocial profile, and thus appropriate counseling resources could be targeted to them.

A longitudinal study of psychological distress in a cohort of gay men. Effects of social support and coping strategies.

This study presents analyses on questionnaire data collected from a panel of 520 gay men at risk for acquired immune deficiency syndrome, enrolled in the Coping and Change Study (1985-1987). The data were assessed to determine the association of social support and coping styles with subsequent depression and global distress and to investigate whether these predictors of mental health are stable or transient over time. Three different measures of the subjective, qualitative nature of social support were significantly associated with subsequent mental health. Those who reported a subjective sense of isolation experienced significantly more adverse mental health 6 months later at all three measurement periods. Scattered effects were found for perceived social conflict and perceived social support from others. These results indicate that certain types of social support appear to influence mental health in this cohort and, furthermore, that some associations are transient and others more stable over time.

Recreational drugs and sexual behavior in the Chicago MACS/CCS cohort of homosexually active men. Chicago Multicenter AIDS Cohort Study (MACS)/Coping and Change Study.

Since initial reports emerged of an association between recreational drug use and high-risk sexual behaviors in gay men, there has been interest in studying this relationship for its relevance to behavioral interventions. Reported here are the longitudinal patterns of alcohol and recreational drug use in the Chicago Multicenter AIDS Cohort Study (MACS)/Coping and Change Study (CCS) of gay men. A pattern of decreasing drug use over 6 years was observed that paralleled a decline in high-risk sexual behavior (i.e., unprotected anal intercourse). In contrast, alcohol consumption tended to be more stable over time, and to show no relationship to sexual behavior change. Men who combined volatile nitrite (popper) use with other recreational drugs were at highest risk both behaviorally and in terms of human immunodeficiency virus-1 (HIV) seroconversion throughout the study. Popper use also was associated independently with lapse from safer sexual behaviors (failure to use a condom during receptive anal sex). Use of other recreational substances showed no relationship to sexual behavior change patterns, and stopping popper use was unrelated to improvement in safer sexual behavior. When popper use and lapse from safer sex were reanalyzed, controlling for primary relationship status, popper use was associated with failure to use condoms during receptive anal sex among nonmonogamous men only. These findings suggest an association between popper use and high-risk sexual behavior among members of the Chicago MACS/CCS cohort that has relevance to HIV prevention intervention efforts.

Assessing risk factors for transmission of infection.

Commonly used measures of effect, such as risk ratios and odds ratios, may be quite biased when used to assess the effect of factors that alter transmission risks given exposure to infected individuals. This is demonstrated in a simulation model involving a higher-risk behavior and a lower-risk behavior affecting the sexual transmission of human immunodeficiency virus. The bias arises because population contact patterns between higher-risk and lower-risk persons change their relative probabilities of exposure to an infected individual as an epidemic progresses. The assessment of contact patterns is thus central to risk assessment for contagious diseases. A new formulation of selective mixing presented here, together with a structured mixing specification of the social settings of contact, provides a theoretic framework for the investigation of contact pattern determinants.