Brett M. Millar

Patterns of substance use among HIV-positive adults over 50: implications for treatment and medication adherence.

BACKGROUND The population of older adults living with HIV is increasing in the United States. Despite an increased focus on the health of HIV-positive older adults, knowledge about their substance use, a primary risk factor for HIV medication non-adherence, and the association between use, problems associated with use, and adherence behavior, is limited. METHODS Data were collected from 557 HIV-positive adults aged 50 and older in the New York City area via telephone interview. Participants reported the number of days in the past month on which they missed any doses of HIV medication as well as the number of days they used alcohol, marijuana, cocaine/crack, opiates, amyl nitrite (poppers), and other drugs. The severity of substance use associated problems was assessed using the DAST-10 and AUDIT-C. RESULTS The sample included gay/bisexual (40.4%) and heterosexual (28.1%) men as well as lesbian/bisexual (4.9%) and heterosexual (26.7%) women. Latent class analyses identified four distinct patterns of substance use: Exclusive Alcohol Use; Alcohol and Marijuana; Alcohol and Cocaine/Crack; and Multiple-Substance Use. Variability in the number of missed HIV medication days and perceptions of substance use associated problems were observed across classes, with poorest adherence reported in the Alcohol and Marijuana class, the Alcohol and Cocaine/Crack class, and the Multiple-Substance Use class. The latter two classes also reported the greatest perceived impairment from substance use. CONCLUSIONS Patterns of recent substance use were associated with varying levels of HIV medication adherence and perceived substance use impairment, indicating that substance type matters when considering the health of older adults living with HIV, and that multiple-substance use needs to be addressed by interventions aimed at improving medication adherence.

Syndemic factors associated with HIV risk for gay and bisexual men: comparing latent class and latent factor modeling.

Abstract Syndemics theory has been proposed as a framework for understanding the role of multiple risk factors driving the HIV epidemic among gay and bisexual men. Previous studies have examined five syndemic indicators (polydrug use, depression, childhood sexual abuse, sexual compulsivity, and intimate partner violence). Many of these studies have utilized sum scores, the total number of syndemic factors endorsed, to quantify syndemic stress. This approach assumes a unidimensional latent factor and equivalence of factor loadings. It also overlooks the possibility that patterns, or classes, of syndemic factor endorsement may be present. The current study utilized survey data from 669 gay and bisexual men to test assumptions of unidimensionality and factor loading equivalence and to examine the utility of identifying latent classes of syndemic stress. Analysis supported operationalizing syndemics as a unidimensional latent factor. Assumptions of loading equality were not supported. Meaningful profiles of syndemic stress were not evident in latent class analysis results.

Sexual Risk-Taking in HIV-Negative Gay and Bisexual Men Increases with Depression: Results from a U.S. National Study.

The link between depression and sexual risk-taking has received mixed findings in the literature. The current study analyzed the links between depression and recent condomless anal sex (CAS) with casual partners among 1033 HIV-negative, non-PrEP-using, gay and bisexual men. When CAS was dichotomized as either none or some, depression was not associated with the odds of CAS (with receptive and insertive combined) or insertive CAS only, but was positively associated with the odds of receptive CAS. When CAS was tallied as a count variable of events, depression was positively associated with total CAS, receptive CAS, and insertive CAS. With the addition of a quadratic term for depression, a positive quadratic effect was only found for total CAS and receptive CAS, but not for insertive CAS. These findings highlight the utility of using count data for CAS events and treating CAS separately with regard to receptive and insertive positioning when considering the role of depression among gay and bisexual men.ResumenEl enlace entre la depresión y el riesgo sexual ha recibido resultados mixtos en la literatura. El presente estudio analizó los vínculos entre la depresión y el sexo anal sin condón reciente (CAS, siglas en Inglés) con parejas ocasionales en 1033 hombres gay y bisexuales VIH-negativo que no utilizaban PrEP. Cuando dicotomizada a algún o ningún episodio de CAS, la depresión no estuvo asociada con la probabilidad de CAS (con receptivo e insertivo combinados) o CAS insertivo solamente, pero sí estuvo asociada positivamente con la probabilidad de CAS receptivo. Cuando el CAS se contabilizó como una variable de recuento de los acontecimientos, la depresión se asoció positivamente con el número total de CAS, con el CAS receptivo, y el CAS insertivo. Con la adición de un término cuadrático para la depresión, un efecto cuadrático positivo sólo se encontró para el CAS total y CAS receptivo, pero no para el CAS insertivo. Estos resultados resaltan la utilidad de usar los datos de recuento de acontecimientos del CAS y de tratar el CAS por separado con respecto a la posición receptiva e insertiva al considerar el rol de la depresión entre hombres gays y bisexuales.

Predictors of Condom Use With Main and Casual Partners Among HIV-Positive Men Over 50

OBJECTIVE Sexual health among the growing population of older adults living with HIV has garnered increased research attention. Previous studies have identified alcohol and drug use as factors increasing rates of sexual activity and sex risk behavior in this population. However, the influence of partner type (whether main or casual) on the links between substance use and sexual behavior in older men living with HIV remains understudied and was the focus of the current study. METHOD Data were collected from telephone interviews with 378 men, aged 50 years or older, living with HIV and residing in the New York City area. The sample included 224 (59%) men who identified as gay or bisexual and 154 (41%) who identified as heterosexual. The majority of the sample identified as Black (66%), and the average age was 55 years. Participants reported on recent sexual behavior, substance use, and viral load/detectability status. RESULTS Results of multinomial logistic regression analyses found that substance use was associated with increased rates of condomless sex with casual partners but not with main partners, whereas self-reported viral load (perceptions of immunological health) was a factor associated with condomless sex with main partners but not with casual partners. CONCLUSIONS The findings indicate that different factors are involved in instances of condomless sex depending on whether the partner is a main or casual partner. Research and intervention efforts aimed at reducing risk factors for older men living with HIV and their partners need to take into account the relational context of sexual behavior.

The moderating role of internalized homonegativity on the efficacy of LGB-affirmative psychotherapy: results from a randomized controlled trial with young adult gay and bisexual men

OBJECTIVE As empirical evidence for the effectiveness of LGB-affirmative psychotherapy emerges, the question of whether some clients may derive greater benefit than others becomes important. The current study investigated whether internalized homonegativity (IH), both explicit and implicit, moderated the efficacy of a cognitive-behavioral intervention designed to improve the mental and sexual health of young gay and bisexual men through facilitating minority stress coping. METHOD At baseline, young gay and bisexual men (n = 54) experiencing symptoms of depression and anxiety completed measures of explicit and implicit IH. Participants also completed self-reports of mental health and an interviewer-based assessment of past-90-day risk behavior before and after treatment in a 10-session individual LGB-affirmative intervention. RESULTS Moderation analyses showed that participants higher in implicit IH experienced greater reductions in depression (b = -2.99, p = .031, 95% confidence interval [CI] [-5.69, -0.29]), anxiety (b = -3.56, p = .014, 95% CI [-6.35, -0.76]), and past-90-day condomless anal sex with casual partners (b = -1.29, p = .028, 95% CI [-2.44, -0.14]). Participants higher in explicit IH experienced greater reductions in past-90-day heavy drinking (b = -0.42, p = .003, 95% CI [-0.69, -0.15]). CONCLUSIONS These findings indicate that greater gains from LGB-affirmative psychotherapy were observed in gay and bisexual men who were higher in IH, particularly when measured implicitly. As the first study that examines factors moderating the efficacy of LGB-affirmative psychotherapy, the present research has important implications for intervention development and highlights the value of incorporating implicit measures into clinical work. (PsycINFO Database Record

Syndemic conditions and HIV transmission risk behavior among HIV-negative gay and bisexual men in a U.S. national sample.

Objective: The syndemics framework has been used to explain the high rates of HIV infection among gay and bisexual men. However, most studies have relied primarily on urban or otherwise limited (e.g., single location) samples. We evaluated the prevalence of syndemics—here, depression, polydrug use, childhood sexual abuse, intimate partner violence, and sexual compulsivity—among gay and bisexual men from across the United States, including nonurban areas. Method: Using data from a national sample of 1,033 HIV-negative gay and bisexual men, demographic differences in the prevalence of each syndemic condition and associations with HIV transmission risk behavior were examined. Results: More than 62% of men reported at least 1 syndemic condition. Prevalence did not vary by U.S. region—however, a larger proportion of nonurban men and those with lower income and education levels were above the median number of syndemic conditions. In bivariate analyses, HIV transmission risk behavior was associated with each syndemic condition except for childhood sexual abuse, whereas in multivariate analyses, it was associated with polydrug use, sexual compulsivity, being Latino, and being single and was highest among those reporting 3 or more syndemic conditions. Conclusions: Rates of syndemic conditions among this national sample of gay and bisexual men were generally comparable to previous studies, however elevated rates in nonurban men suggest the need for targeted intervention and support. Links observed between syndemics and HIV transmission risk behavior highlight the ongoing need to address psychosocial concerns among gay and bisexual men in order to reduce their disproportionately high rates of HIV infection.

The Impact of Comorbidities, Depression, and Substance Use Problems on Quality of Life Among Older Adults Living With HIV

Older adults living with HIV (OALWH) comprise a growing population with a range of complex and interconnecting medical and psychosocial needs. Based on the biopsychosocial model with its emphasis on a holistic approach to various aspects of people’s lives, the current study explored associations between physical health, psychological health, substance use, and overall quality of life. Drawing on data from 114 substance-using OALWH (aged 50 or older), we employed linear regression to show associations between the number of current comorbid health conditions on quality of life, over and above depression, substance use problems, and demographic characteristics (age, race/ethnicity, gender, sexual orientation, education, and relationship status). In both bivariate and multivariable contexts, the number of comorbid conditions was associated with reduced quality of life. Depression and substance use were also negatively associated with quality of life. These findings indicate that clinical and supportive care for OALWH, particularly when related to mental health and substance use, should also include an integrated focus on the comparatively high number of current comorbid conditions that often accompany, and potentially complicate, HIV treatment and quality of life.

Modeling Interpersonal Correlates of Condomless Anal Sex among Gay and Bisexual Men: An Application of Attachment Theory

Abstract The existing literature has identified that beliefs about the interpersonal meaning of condom use are a significant predictor of condomless anal sex (CAS). Some have suggested that condom use in this context may function as a form of nonverbal communication. This study utilized attachment theory as a framework and tested a hypothesized model linking adult attachment to CAS through communication skills and condom expectancies. An online survey was completed by 122 single, HIV-negative gay and bisexual (GB) men living in the U.S. They completed measures of adult attachment (anxious and avoidant), condom expectancies regarding intimacy and pleasure interference, communication skills, self-assessed mate value, and recent CAS with casual partners. There was a significant, positive bivariate association between anxious attachment and receptive CAS. In path model analyses, two over-arching pathways emerged. In the other-oriented pathway, anxious attachment, self-perceived mate value, and emotional communication predicted the belief that condoms interfere with intimacy. In turn, intimacy interference expectancies were positively associated with the odds of receptive CAS. In the self-oriented pathway, assertive communication skills mediated a link between avoidant attachment and the belief that condoms interfere with sexual pleasure. Pleasure interference expectancies were positively associated with the odds of insertive CAS. The findings highlight the importance of relational or interpersonal concerns in sexual risk-taking among single GB men. Attachment theory may serve as a framework for organizing these interpersonal correlates of CAS. Results are consistent with the conceptualization of condom use as a form of nonverbal attachment-related behavior. Implications for sexual health and risk-reduction interventions are explored in this context.

The role of sexual expectancies of substance use as a mediator between adult attachment and drug use among gay and bisexual men

BACKGROUND Research exploring substance use in gay and bisexual men has increasingly paid attention to interpersonal dynamics and relational concerns associated with the use of substances. The current study explored the role of adult attachment style on drug use as well as the potential mediating role of sexual expectancies of substance use among gay and bisexual men. METHODS Online survey data were gathered from 122 gay and bisexual men across the U.S., with a mean age of 33 years. All participants were HIV-negative and identified their relationship status as single. Survey measures included attachment style, sexual expectancies of substance use, and recent drug use. RESULTS While neither anxious or avoidant attachment were directly associated with the odds of recent drug use, they were positively associated with sexual expectancies of substance use (β=0.27, p<0.01, and β=0.21, p<0.05) which, in turn, were positively associated with the odds of drug use (expB=1.09, p<0.01). Bootstrapping tests of indirect effects revealed a significant indirect relationship between anxious attachment and drug use through sexual expectancies of substance use (β=0.11, p<0.05), but not for avoidant attachment. CONCLUSIONS This study highlights the importance of interpersonal expectancies as motivators for drug use among gay and bisexual men. Sexual expectancies of substance use were associated with drug use and anxious adult attachment was associated indirectly with drug use through these sexual expectancies.

The Critical Role of Internalized HIV-Related Stigma in the Daily Negative Affective Experiences of HIV-Positive Gay and Bisexual Men

BACKGROUND Research suggests that HIV stigma exerts a detrimental impact on the mental health of HIV-positive gay and bisexual men (GBM). We sought to better understand these processes by examining two forms of HIV stigma (i.e., anticipated and internalized) at two levels (i.e., individual and situational) in association with daily negative affective experiences. METHODS We conducted a 21-day twice-daily ecological momentary assessment study of 51 HIV-positive GBM. Twice-daily stigma measures were disaggregated into individual-level averages and situational fluctuations, and we utilized multilevel models to examine both concurrent and time-lagged effects of HIV stigma on anxious affect, depressed affect, anger, fatigue, and emotion dysregulation. RESULTS Situational experiences of internalized HIV stigma were associated with increased levels of anxious and depressed affect, anger, and emotion dysregulation in both concurrent and time-lagged analyses. Situational experiences of anticipated HIV stigma were only associated with anger and only within concurrent analyses. Individual-level internalized HIV stigma was associated with anxious affect and emotion dysregulation in both concurrent and time-lagged models, and with depressed affect and fatigue in time-lagged models. LIMITATIONS The small and high-risk sample limits generalizability and results should be replicated in larger and more diverse samples. CONCLUSIONS These findings suggest that, independent of the effects of individual-level stigma, situational experiences of internalized HIV stigma are associated with increases in event-level negative affective experiences. A combination of individually-delivered and mobile interventions may be successful at reducing the impact of internalized HIV stigma on negative affect and emotion dysregulation.