David G. Ostrow

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.

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.

Psychosocial and Public Health Impacts of New HIV Therapies

1. Combination Antiretroviral Chemotherapy: Shifting Paradigms and Evolving Praxis K.H. Mayer. 2. Pharmacokinetics of Protease Inhibitors and Drug Interactions with Psychoactive Drugs S.K. Chuck, et al. 3. Treatment Adherence to HIV Medications: The Achilles Heel of the New Therapeutics J.G. Rabkin, M. Chesney. 4. Combination Antiretroviral Therapies for HIV: Some Economic Considerations S.D. Pinkerton, D.R. Holtgrave. 5. Ethical Issues in the Use of New Treatment for HIV E. Heitman, M.W. Ross. 6. Mental Health Implications of new HIV Treatments S.C. Kalichman, B. Ramachandran. 7. Practical Prevention Issues D.G. Ostrow. 8. Postexposure Prophylaxis: A Community Members Perspectives M. Shriver. 9. Behavioral Research Needs and Challenges of Nnew Treatments: AIDS as a Chronic Illness W. Pequegnat, E. Stover. Glossary. Index.

Patterns and Correlates of Risky Behavior Among HIV+ Gay Men: Are They Really Different from HIV − Men?

With the advent of highly effective antiretroviral therapies, the prospects for persons living with HIV infection (HIV+) undoubtedly include many years of continued sexual activity. Reports of unsafe sexual behavior among a subset of HIV+ men has alarmed some prevention researchers and stimulated rethinking of HIV prevention interventions for gay/bisexual men. This paper examines the rates of unsafe sex among HIV+ gay/bisexual men and their correlates, comparing them to HIV− men recruited simultaneously to the Chicago MACS/C&CS and AIM studies. Aside from initial differences in the rates of unprotected anal sex (UAS) among men prior to learning their HIV serostatus, there were no differences in actual rates of UAS or their correlates in the two samples. Further, the importance of attitudinal measures—i.e., sexual sensation seeking, preference for UAS, and belief in the efficacy of the new therapies—in predicting risky sex among gay/bisexual men regardless of serostatus argues for an emphasis on modifying these attitudes in any HIV prevention interventions for gay and bisexual men and the importance of combining primary and secondary HIV prevention strategies whenever possible.

Sexual Adventurism, Substance Use, and High-Risk Sexual Behavior: A Structural Modeling Analysis of the Chicago MACS/Coping and Change Cohort

The purpose of this study was to model the relationships between dispositional tendencies towards sexual risk seeking (sexual adventurism) and engaging in risky behaviors (e.g., unprotected anal intercourse and recreational drug use). We analyzed data collected at semiannual assessments, between 1984 and 1993, from gay/bisexual participants in both the Chicago Multicenter AIDS Cohort Study (MACS) and the Coping and Change Study (CCS). Factor analysis on 34 items from the CCS questionnaires guided the construction of an index of “sexual adventurism/risk-seeking” which was then used in univariate and multivariate analyses to determine its relationship, across time, with the outcome behaviors of drug use and risky sex. Path analysis models then assessed the relative importance of sexual adventurism and drug use covariates for predicting risky sex in subsequent assessments. Sexual adventurism was significantly associated with both substance use and risky sex at all time periods. Multivariate analyses revealed this relationship to be independent of drug use; however, this was not true for the association between risky sex and drugs. Path analysis confirmed the causal links (either direct or mediated by drug use) between sexual adventurism and risky sex. Substance use had little, if any, direct association with high-risk sexual behavior when sexual adventurism was included in the models. These findings support the existence of a common underlying dispositional factor, sexual adventurism/risk seeking, that would be a major determinant of the association between risky sex and drug use among gay men. Similar findings from other studies indicate the wider potential applicability of sexual adventurism/risk-seeking measures and suggest the need for focused intervention efforts in targeting this subgroup of high-risk individuals.

Living with HIV infection

By its chronic nature, HIV infection represents a period of time where persons are coping with the social and physiological changes of the infection across the spectrum of acute infection, illness, and death. As a person moves through the stages of infection, he or she also experiences different psychological states, whether they be a reaction to the disease process itself, to social reactions to HIV/AIDS, or to the threat of developing AIDS in the future. The purpose of this article is to describe in both quantitative and qualitative terms the psychosocial functioning of infected men from the time they learn they are seropositive to their demise, and to contrast this to seronegative men. This paper specifically examines the longitudinal patterns of psychological states, social support, social conflict, and HIV-risk behavior as measured prospectively in a cohort of homosexual men in Chicago. The men participating in the Chicago Multicenter AIDS Cohort and Coping and Change Studies enrolled in 1984, before...

Methodological Issues in HIV Behavioral Interventions

Human immunodeficiency virus (HIV) behavioral intervention research involves numerous methodological issues that are either unique to the field of HIV research or “cutting edge” in terms of behavioral research in general. The thrust of this chapter will be to review those issues that are either the most important new HIV prevention research issues or the most limiting in the areas of “sensitive” behavioral research (i.e., research on sexual, drug use, and other socially “sensitive” behaviors) in general. With the current trend to integrate HIV research and prevention activities into the larger domains of behavioral prevention and sexually transmitted diseases (STDs) in general, some of the issues and examples discussed in this chapter may go well beyond the purview of HIV intervention research per se. However, they have been selected for discussion here because of their key influence on the directions and opportunities that HIV prevention research are predicted to be going in the next 5–10 years. We have used the schema of an earlier publication, Methodological Issues in AIDS Behavioral Research,1 in discussing methodological issues by design, sampling and retention, measurement, and analytical/modeling issues and focus on topics that have progressed or changed the most since that book was published in 1993.

Hepatitis and HIV Risk among Drug-Using Men Who Have Sex with Men: Demonstration of Hart's Law of Inverse Access and Application to HIV

Objectives: The first 215 drug-using men who have sex with men (DU-MSM) evaluated for possible participation in a controlled behavioral intervention study were tested for “Harts law of inverse access,” which predicts that access to prevention resources varies inversely to need. Methods: Hepatitis B vaccination, mental health, and substance abuse treatment were used to measure health resource use; hepatitis B (HBV) and HIV infections and unsafe sex measured preventive care needs. Socioeconomic status indicators included education, ethnicity, and income. Results: HBV-vaccinated men were more likely to be white and college educated. HBV-infected men were more likely to be black, older, HIV-positive, and have higher rates of substance use with sex. When stratified according to socioeconomic status indicators, levels of HBV vaccination were inverse to the rates of HBV and HIV infection. This relationship was not found for psychosocial treatment utilization. Conclusions: Demonstration of Harts law among high-risk DU-MSM has important implications for future HIV prevention efforts among high-risk individuals. Combining HIV, hepatitis, and substance abuse prevention in primary care and substance abuse treatment settings is discussed.

Behavioral interventions for the primary prevention of HIV infection among homosexual and bisexual men.

Behavioral intervention is the most urgent priority in preventing the further spread of HIV. To maximize the efficacy of AIDS prevention and to most efficiently allocate resources, it is imperative that variables contributing to preventive behavior change be accurately identified, and interventions be critical evaluated prior to widespread dissemination. We review studies regarding homosexual/bisexual men in terms of: 1) epidemiological trends in HIV transmission; 2) models of behavior change organized around the initiation, consolidation, and maintenance of change, and; 3) preventive intervention outcomes. We conclude with recommendations for effective primary prevention programs.

Psychoanalytic and Behavioral Approaches to Drug-Related Sexual Risk Taking

Abstract The topic of substance abuse among gay and bisexual men is of intense topical interest precisely because of the demonstrated co-occurrence of “recreational” substance use and HIV infection among gay/bisexual men. With the discovery of the Human Immunodeficiency Virus Type-I (HIV), it has been consistently shown that both prevalent and incident HIV infections are significantly associated with a history of substance use or abuse. In an attempt to integrate both cognitive-behavioral models and psychoanalytical understandings of our drug using/sexual risk-taking patients, the authors have engaged in the exchange of ideas and case reports over the past several years. This paper summarizes the results of those exchanges and utilizes two clinical case examples as the basis for identifying the utility of an integrated psychoanalytical and behavioral approach to clinical conceptualization and treatment.