Paul A. Shuper

Causal considerations on alcohol and HIV/AIDS--a systematic review.

AIMnThe study aimed to explore the possible causal nature of the association between alcohol consumption and HIV/AIDS.nnnMETHODSnA review based on meta-analyses and reviews was conducted according to standard epidemiological criteria to distinguish causality from association, examining (i) the potential impact of alcohol on the incidence of HIV and (ii) alcohols impact on worsening the disease course.nnnRESULTSnIn terms of incidence of HIV, although we found a consistent and strong association with consumption, there was not enough evidence for a causal connection. In particular, it is not clear whether personality traits such as sensation seeking or sexual compulsivity and psychiatric disorders such as antisocial personality disorder impact both alcohol consumption and risky sex, subsequently creating an association between both behaviors. In terms of worsening the disease course of HIV/AIDS, we found enough evidence for a causal impact of alcohol. Alcohol affects the immune system, thus contributing to a worsened course of HIV/AIDS. In addition, alcohol negatively impacts on behaviors that include support seeking and medication adherence.nnnCONCLUSIONSnA randomized controlled clinical trial targeted toward at-risk HIV-negative individuals who live in areas with high HIV prevalence is suggested to test the effects of proven effective alcohol interventions on HIV incidence.

Alcohol as a Correlate of Unprotected Sexual Behavior Among People Living with HIV/AIDS: Review and Meta-Analysis

The present investigation attempted to quantify the relationship between alcohol consumption and unprotected sexual behavior among people living with HIV/AIDS (PLWHA). A comprehensive search of the literature was performed to identify key studies on alcohol and sexual risk behavior among PLWHA, and three separate meta-analyses were conducted to examine associations between unprotected sex and (1) any alcohol consumption, (2) problematic drinking, and (3) alcohol use in sexual contexts. Based on 27 relevant studies, meta-analyses demonstrated that any alcohol consumption (ORxa0=xa01.63, CIxa0=xa01.39–1.91), problematic drinking (ORxa0=xa01.69, CIxa0=xa01.45–1.97), and alcohol use in sexual contexts (ORxa0=xa01.98, CIxa0=xa01.63–2.39) were all found to be significantly associated with unprotected sex among PLWHA. Taken together, these results suggest that there is a significant link between PLWHA’s use of alcohol and their engagement in high-risk sexual behavior. These findings have implications for the development of interventions to reduce HIV transmission risk behavior in this population.

The relationship between different dimensions of alcohol use and the burden of disease-an update.

Abstract Background and aims Alcohol use is a major contributor to injuries, mortality and the burden of disease. This review updates knowledge on risk relations between dimensions of alcohol use and health outcomes to be used in global and national Comparative Risk Assessments (CRAs). Methods Systematic review of reviews and meta‐analyses on alcohol consumption and health outcomes attributable to alcohol use. For dimensions of exposure: volume of alcohol use, blood alcohol concentration and patterns of drinking, in particular heavy drinking occasions were studied. For liver cirrhosis, quality of alcohol was additionally considered. For all outcomes (mortality and/or morbidity): cause of death and disease/injury categories based on International Classification of Diseases (ICD) codes used in global CRAs; harm to others. Results In total, 255 reviews and meta‐analyses were identified. Alcohol use was found to be linked causally to many disease and injury categories, with more than 40 ICD‐10 three‐digit categories being fully attributable to alcohol. Most partially attributable disease categories showed monotonic relationships with volume of alcohol use: the more alcohol consumed, the higher the risk of disease or death. Exceptions were ischaemic diseases and diabetes, with curvilinear relationships, and with beneficial effects of light to moderate drinking in people without heavy irregular drinking occasions. Biological pathways suggest an impact of heavy drinking occasions on additional diseases; however, the lack of medical epidemiological studies measuring this dimension of alcohol use precluded an in‐depth analysis. For injuries, except suicide, blood alcohol concentration was the most important dimension of alcohol use. Alcohol use caused marked harm to others, which has not yet been researched sufficiently. Conclusions Research since 2010 confirms the importance of alcohol use as a risk factor for disease and injuries; for some health outcomes, more than one dimension of use needs to be considered. Epidemiological studies should include measurement of heavy drinking occasions in line with biological knowledge.

Computer-Based Intervention in HIV Clinical Care Setting Improves Antiretroviral Adherence: The LifeWindows Project

We evaluated the efficacy of LifeWindows, a theory-based, computer-administered antiretroviral (ARV) therapy adherence support intervention, delivered to HIVxa0+xa0patients at routine clinical care visits. 594 HIVxa0+xa0adults receiving HIV care at five clinics were randomized to intervention or control arms. Intervention vs. control impact in the intent-to-treat sample (including participants whose ARVs had been entirely discontinued, who infrequently attended care, or infrequently used LifeWindows) did not reach significance. Intervention impact in the On Protocol sample (328 intervention and control arm participants whose ARVs were not discontinued, who attended care and were exposed to LifeWindows regularly) was significant. On Protocol intervention vs. control participants achieved significantly higher levels of perfect 3-day ACTG-assessed adherence over time, with sensitivity analyses maintaining this effect down to 70% adherence. This study supports the utility of LifeWindows and illustrates that patients on ARVs who persist in care at clinical care sites can benefit from adherence promotion software.ResumenEvaluamos la eficacia de LifeWindows, una intervención de apoyo para la adherencia a la terapia antirretroviral (TAR) basada en teoría y con administración informatizada para pacientes con VIHxa0+xa0en sus visitas clínicas rutinarias. 594 adultos de cinco clínicas con VIHxa0+xa0y bajo tratamiento fueron aleatoriamente asignados a un grupo de intervención o de control. No se alcanzó significación estadística al comparar ambos grupos bajo la estrategia de ‘intención de tratar’ (incluyendo los participantes cuyos TAR se habían interrumpido por completo, habían asistido a la clínica en pocas ocasiones, o usaron LifeWindows con poca frecuencia). Sin embargo, la intervención obtuvo un impacto significativo cuando se evaluó con la muestra bajo Protocolo (un total de 328 participantes cuyos TAR no fueron interrumpidos, asistieron a sus visitas clínicas y se expusieron a LifeWindows regularmente). Los participantes bajo Protocolo de intervención obtuvieron niveles más altos de adherencia que el grupo control en tres días de Estudios de Grupos Clinicos con SIDA (EGCS) con repetidas evaluaciones y manteniendo como mínimo un 70% de la adherencia. Este estudio apoya la utilidad de LifeWindows e indica que los pacientes con TAR que asisten a las visitas clínicas, pueden beneficiarse de este software de promoción de la adherencia.

Personality as a Predictor of Unprotected Sexual Behavior Among People Living with HIV/AIDS: A Systematic Review

The present investigation involved a systematic literature review to (1) identify associations between personality constructs and unprotected sex among people living with HIV/AIDS (PLWH); (2) assess patterns of direct versus indirect personality-risky sex associations; and (3) explore possible differences in personality-risky sex associations among PLWH versus non-infected populations. Among the 26 studies yielded through the systematic search, sensation seeking and sexual compulsivity were the constructs most frequently examined, with fewer studies investigating traditional personality typologies. Personality constructs that were more conceptually proximal to the sexual act, such as sexual compulsivity and sex-related sub-components of sensation seeking, showed relatively direct associations with unprotected sex, whereas more conceptually distal constructs such as generalized impulsivity demonstrated only weak or indirect associations. Associations were also frequently mediated by other risk factors, including perceived responsibility and substance use. These findings have implications for the development of interventions to reduce high risk sexual behavior among PLWH.

The Impact of Sexual Arousal on Sexual Risk-Taking and Decision-Making in Men and Women.

Sexual arousal has emerged as an important contextual feature in sexual encounters that can impact safer-sex decision-making. We conducted two experiments that investigated the effects of sexual arousal among male and female participants. Experiment 1 (Nxa0=xa0144) examined the impact of sexual around on sexual health decision-making. Sexually explicit and neutral video clips as well as hypothetical romantic scenarios were used to evaluate the effects of sexual arousal on sexual risk-taking intentions. Men and women who reported higher levels of sexual arousal also displayed greater intentions to participate in risky sexual behavior (e.g., unprotected sex with a new sex partner). Experiment 2 (Nxa0=xa0122) examined the impact of sexual arousal on general risk-taking, using the same videos clips as in Experiment 1 and a modified version of a computerized Blackjack card game. Participants were offered a chance to make either a risky play or a safe play during ambiguous conditions. Increased sexual arousal in Experiment 2 was associated with impulsivity and a greater willingness to make risky plays in the Blackjack game. These findings suggest that, in situations where there are strong sexually visceral cues, both men and women experiencing strong sexual arousal may have lower inhibitions and may experience impaired decision-making. This phenomenon may have an impact during sexual encounters and may contribute to a failure to use appropriate prophylactic protection.

Gender Differences in Severity and Correlates of Depression Symptoms in People Living with HIV in Ontario, Canada.

This study investigates the differences in severity and correlates of depression symptoms among 1069 men and 267 women living with HIV in Ontario, Canada, who completed the 20-item Center for Epidemiologic Studies Depression Scale (CES-D). Women had higher CES-D scores than that of men (median [interquartile range]: 13 [5-26] versus 9 [3-20], P = .0004). More women had total CES-D scores >15 (mild-moderate depression; 44% versus 33%, P = .002) and >21 (severe depression; 31% versus 23%, P = .003). Unlike men, at age 40, women’s scores increased yearly (0.4 per increased year, P = .005). The distribution of scores differed by gender: There was no difference in the 10th percentile of depression scores, 0 (95% confidence interval [CI]: 1.0-1.0) but the 75th percentile of depression scores for women was 6 (95% CI: 2.0-10.0) points higher than that of men. Important gender differences exist in depression symptoms and in correlates of symptoms in people living with HIV.

Coverage of alcohol consumption by national surveys in South Africa

BACKGROUND AND AIMSnEvidence suggests that adult per-capita alcohol consumption, as estimated from self-reports of nationally representative surveys, underestimates true consumption, as measured as the sum of recorded and unrecorded consumption. The proportion of total adult alcohol per capita reported in representative surveys is usually labelled coverage. The aim of the present paper was to estimate coverage for South Africa under different scenarios of alcohol use assessment and true consumption.nnnDESIGNnFive nationally representative surveys from South Africa were used to estimate the prevalence of drinking and the grams per day among current drinkers. All surveys used a complex multi-stage sampling frame that was accounted for by using survey weights. The total (recorded and unrecorded), the recorded and the adjusted total adult per-capita alcohol consumption in South Africa served as different estimates of the true consumption.nnnSETTINGnSouth Africa.nnnPARTICIPANTSnAlcohol use information was assessed on a total of 8115, 16u2009398 and 13u2009181 adults (15xa0years or older) in surveys from the years 2003, 2005 and 2008, respectively. Two surveys in 2012 included 27u2009070 and 18u2009688 adults.nnnMEASUREMENTSnCoverage of the alcohol use reported in the surveys was calculated, compared with the true adult per-capita alcohol.nnnFINDINGSnThe survey data covered between 11.8% [2005; 95% uncertainty interval (UI)xa0=xa09.3-16.2%)] and 19.4% (2003; 95% UIxa0=xa014.9-24.2%) of the total alcohol used per capita. The highest coverage of 27.9% (95% UIxa0=xa022.4-36.8%) was observed when looking only at recorded alcohol in 2003.nnnCONCLUSIONSnEvidence from five nationally representative surveys assessing alcohol use suggests that less than 20% of the total adult per-capita alcohol consumption in South Africa is reported in surveys.

12-month follow-up of an exploratory ‘brief intervention’ for high-frequency cannabis users among Canadian university students

BackgroundOne in three young people use cannabis in Canada. Cannabis use can be associated with a variety of health problems which occur primarily among intensive/frequent users. Availability and effectiveness of conventional treatment for cannabis use is limited. While Brief Interventions (BIs) have been shown to result in short-term reductions of cannabis use risks or problems, few studies have assessed their longer-term effects. The present study examined 12-month follow-up outcomes for BIs in a cohort of young Canadian high-frequency cannabis users where select short-term effects (3u2009months) had previously been assessed and demonstrated.FindingsNu2009=u2009134 frequent cannabis users were recruited from among university students in Toronto, randomized to either an oral or a written cannabis BI, or corresponding health controls, and assessed in-person at baseline, 3-months, and 12-months. Nu2009=u200972 (54u2009%) of the original sample were retained for follow-up analyses at 12-months where reductions in ‘deep inhalation/breathholding’ (Qu2009=u200913.1; pu2009<u2009.05) and ‘driving after cannabis use’ (Qu2009=u20099.3; pu2009<u2009.05) were observed in the experimental groups. Reductions for these indicators had been shown at 3-months in the experimental groups; these reductions were maintained over the year. Other indicators assessed remained overall stable in both experimental and control groups.ConclusionsThe results confirm findings from select other studies indicating the potential for longer-term and sustained risk reduction effects of BIs for cannabis use. While further research is needed on the long-term effects of BIs, these may be a valuable – and efficient – intervention tool in a public health approach to high-risk cannabis use.

Protocol for a Controlled Experiment to Identify the Causal Role of Acute Alcohol Consumption in Condomless Sex among HIV-Positive MSM: Study Procedures, Ethical Considerations, and Implications for HIV Prevention.

AbstractAlthough alcohol consumption is frequently perceived as a driver of condomless sex and subsequent HIV acquisition, the causal nature of this relationship remains unclear, and little is known about alcohol’s direct versus indirect impact on the sexual risk dynamics of those who are HIV-positive. To address this gap, we present the protocol for an in-progress NIAAA-funded controlled experiment, wherein a sample of HIV-positive men-who-have-sex-with-men (MSM) undergoes an alcohol consumption manipulation (alcohol/placebo/control) and sexual arousal induction (sexually aroused/non-aroused), and then reports intentions to engage in condom-protected and condomless sexual acts with hypothetical sexual partners differing in HIV serostatus (HIV+/HIV−/HIV status unknown), condom use preference (use/don’t use/not stated), and physical attractiveness (attractive/unattractive). Study outcomes will identify alcohol’s impact on HIV-positive MSM’s condomless sex intentions in the context of experimentally-manipulated factors as well as risk-relevant personality traits and alcohol-related expectancies. Detailed experimental procedures, ethical considerations, and potential implications for HIV prevention are discussed.n