Sarah E. Woolf-King

Alcohol Use and High-Risk Sexual Behavior in Sub-Saharan Africa: A Narrative Review

Sub-Saharan Africa (SSA) contains 10% of the world’s population and 60% of all people living with AIDS. Consequently, research investigating risk factors associated with HIV acquisition is a public health priority and one such risk factor is alcohol consumption. This article is a review of empirical studies on the association of alcohol and high-risk sexual behavior in SSA, with a focus on measurable outcomes generated from quantitative data. A critique of the literature is provided, with attention to methodological concerns. Empirically based theoretical orientations were used to interpret the reviewed research and to stimulate discussion about how to improve the state of the current literature. Based on this discussion, a model of alcohol and high-risk sexual behavior in an African context is proposed in order to integrate the existing literature and highlight areas in need of continued research.

Adding fuel to the fire: alcohol's effect on the HIV epidemic in Sub-Saharan Africa.

Alcohol consumption adds fuel to the HIV epidemic in sub-Saharan Africa (SSA). SSA has the highest prevalence of HIV infection and heavy episodic drinking in the world. Alcohol consumption is associated with behaviors such as unprotected sex and poor medication adherence, and biological factors such as increased susceptibility to infection, comorbid conditions, and infectiousness, which may synergistically increase HIV acquisition and onward transmission. Few interventions to decrease alcohol consumption and alcohol-related sexual risk behaviors have been developed or implemented in SSA, and few HIV or health policies or services in SSA address alcohol consumption. Structural interventions, such as regulating the availability, price, and advertising of alcohol, are challenging to implement due to the preponderance of homemade alcohol and beverage industry resistance. This article reviews the current knowledge on how alcohol impacts the HIV epidemic in SSA, summarizes current interventions and policies, and identifies areas for increased research and development.

Declining and rebounding unhealthy alcohol consumption during the first year of HIV care in rural Uganda, using phosphatidylethanol to augment self-report.

AIMS We examined whether unhealthy alcohol consumption, which negatively impacts HIV outcomes, changes after HIV care entry overall and by several factors. We also compared using phosphatidylethanol (PEth, an alcohol biomarker) to augment self-report to using self-report alone. DESIGN A prospective 1-year observational cohort study with quarterly visits. SETTING Large rural HIV clinic in Mbarara, Uganda. PARTICIPANTS A total of 208 adults (89 women and 119 men) entering HIV care, reporting any prior year alcohol consumption. MEASUREMENTS Unhealthy drinking was PEth+ (≥ 50 ng/ml) or Alcohol Use Disorders Identification Test-Consumption+ (AUDIT-C+, over 3 months, women ≥ 3; men ≥ 4). We calculated adjusted odds ratios (AOR) for unhealthy drinking per month since baseline, and interactions of month since baseline with perceived health, number of HIV symptoms, antiretroviral therapy (ART), gender and self-reported prior unhealthy alcohol use. FINDINGS The majority of participants (64%) were unhealthy drinkers (PEth+ or AUDIT-C+) at baseline. There was no significant trend in unhealthy drinking overall [per-month AOR: 1.01; 95% confidence interval (CI) = 0.94-1.07], while the per-month AORs were 0.91 (95% CI = 0.83-1.00) and 1.11 (95% CI = 1.01-1.22) when participants were not yet on ART and on ART, respectively (interaction P-value < 0.01). In contrast, 44% were AUDIT-C+; the per-month AORs for being AUDIT-C+ were 0.89 (95% CI = 0.85-0.95) overall, and 0.84 (95% CI = 0.78-0.91) and 0.97 (95% CI = 0.89-1.05) when participants were not on and were on ART, respectively. CONCLUSIONS Unhealthy alcohol use among Ugandan adults entering HIV care declines prior to the start of anti-retroviral therapy but rebounds with time. Augmenting self-reported alcohol use with biomarkers increases the ability of current alcohol use measurements to detect unhealthy alcohol use.

Substance Use and HIV Risk Behavior among Men Who Have Sex with Men: The Role of Sexual Compulsivity

The relationship between substance use, sexual compulsivity and sexual risk behavior was assessed with a probability-based sample of men who have sex with men (MSM). Stimulant, poppers, erectile dysfunction medication (EDM), alcohol use, and sexual compulsivity were independently associated with higher odds of engaging in any serodiscordant unprotected anal intercourse (SDUAI). The association of sexual compulsivity with SDUAI was moderated by poppers and EDM use. Behavioral interventions are needed to optimize biomedical prevention of HIV among substance using MSM.

Mental Health Among Parents of Children With Critical Congenital Heart Defects: A Systematic Review

Background Parents of children with critical congenital heart defects (PCCHDs) may be at high risk for mental health morbidity; however, the literature is not well characterized. Given that compromised parental mental health can lead to long‐term cognitive, health‐related, and behavioral problems in children, a systematic review of this literature could provide informed recommendations for continued research and enhance the care of families of children living with critical congenital heart defects. Methods and Results We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines that resulted in 30 studies on the mental health of PCCHDs. The literature revealed that PCCHDs are at an elevated risk for psychological problems, particularly in the immediate weeks and months following cardiac surgery. Up to 30% of PCCHDs have symptoms consistent with a diagnosis of posttraumatic stress disorder, with over 80% presenting with clinically significant symptoms of trauma; 25% to 50% of PCCHDs reported clinically elevated symptoms of depression and/or anxiety, and 30% to 80% reported experiencing severe psychological distress. There was high variability in measurements used to assess study outcomes, methodological quality, and sociocultural composition of the parents included in the studies. Conclusions There is an urgent need for additional research on the severity, course, persistence, and moderators of these mental health problems over time, and for the development and testing of screening approaches and interventions that can be feasibly delivered in the context of ongoing pediatric cardiac care.

Alcohol use and HIV disease management: The impact of individual and partner-level alcohol use among HIV-positive men who have sex with men

Alcohol use among HIV-positive (HIV+) individuals is associated with decreased adherence to antiretroviral therapy (ART) and consequently poorer HIV treatment outcomes. This study examined the independent association of individual and partner-level alcohol use with HIV disease management among men who have sex with men (MSM) in primary partnerships. In total, 356 HIV+ MSM and their male primary partners completed a baseline visit for a longitudinal study examining the role of couple-level factors in HIV treatment. The Alcohol Use Disorders Identification Test (AUDIT) was administered to assess the individual and the partner-level alcohol use. Primary outcome variables included self-reported ART adherence, ART adherence self-efficacy, and HIV viral load. Results demonstrated that abstainers, compared to hazardous drinkers, had higher self-efficacy to integrate and persevere in HIV treatment and a lower odds of having a detectable viral load. Participants with a partner-abstainer, versus a partner-hazardous drinker, had less self-efficacy to persevere in HIV treatment, a lower odds of 100% three-day adherence and a higher viral load. Together, these findings suggest that assessment and treatment of both the patients and the patients primary partners pattern of alcohol consumption is warranted when attempting to optimize HIV care among MSM.

Stimulant Use and HIV Disease Management Among Men in Same-Sex Relationships

BACKGROUND Research conducted to date has focused primarily on identifying individual-level, psychological determinants of stimulant use and HIV disease management. The present cross-sectional study examined relationship factors as correlates of stimulant use and HIV disease management among men who have sex with men (MSM). METHODS In total, 266 male couples completed a baseline assessment for a cohort study examining the role of relationship factors in HIV treatment. A computer-based assessment of relationship factors, self-reported alcohol and substance use, and self-reported anti-retroviral therapy (ART) adherence was administered. All HIV-positive participants also provided a blood sample to measure viral load. RESULTS After controlling for demographic characteristics and relationship factors, men in a primary relationship with a stimulant-using partner had more than six-fold greater odds of reporting any stimulant use in the past three months. Among HIV-positive participants on ART (n=371), having a stimulant-using partner was independently associated with 67% lower odds of reporting perfect 30-day ART adherence and more than two-fold greater odds of displaying a detectable HIV viral load. In contrast, more partner-level alcohol use was independently associated with greater odds of reporting perfect 3-day ART adherence and lower odds of displaying a detectable HIV viral load. CONCLUSIONS Partner-level stimulant use is an important risk factor for individual-level stimulant use and difficulties with HIV disease management among MSM. To optimize the effectiveness of HIV treatment as prevention, clinical research is needed to develop couples-based interventions targeting stimulant use as a potential driver of detectable HIV viral load.

Selection of Film Clips and Development of a Video for the Investigation of Sexual Decision Making among Men Who Have Sex with Men

Experimental research on sexual decision making is limited, despite the public health importance of such work. We describe formative work conducted in advance of an experimental study designed to evaluate the effects of alcohol intoxication and sexual arousal on risky sexual decision making among men who have sex with men. In Study 1, we describe the procedures for selecting and validating erotic film clips (to be used for the experimental manipulation of arousal). In Study 2, we describe the tailoring of two interactive role-play videos to be used to measure risk perception and communication skills in an analog risky sex situation. Together, these studies illustrate a method for creating experimental stimuli to investigate sexual decision making in a laboratory setting. Research using this approach will support experimental research that affords a stronger basis for drawing causal inferences regarding sexual decision making.

Association of Depressive Symptoms with Lapses in Antiretroviral Medication Adherence Among People Living with HIV: A Test of an Indirect Pathway

Viral suppression, a critical component of HIV care, is more likely when individuals initiate antiretroviral therapy (ART) early in disease progression and maintain optimal levels of adherence to ART regimens. Although several studies have documented the negative association of depressive symptoms with ART adherence, less is known about how depressed mood relates to intentional versus unintentional lapses in adherence as well as the mechanisms underlying this association. The purpose of the current study was to examine the association of depressive symptoms with ART adherence, assessed as a multidimensional construct. Secondarily, this study conducted preliminary indirect path models to determine if medication self-efficacy could explain the depressed mood-adherence relationship. Depressive symptoms were not associated with 95% ART taken, self-reported viral load, deliberate adjustments to ART regimens or skipped ART doses. However, the indirect association of depressive symptoms via decrements in medication self-efficacy was significant for 95% ART taken, self-reported viral load and skipped ART doses, but not deliberate changes to ART regimens. In this sample of HIV-positive outpatients, there is evidence to support medication self-efficacy as a potential mechanism underlying the association between depressive symptoms and ART adherence. Additional longitudinal studies are needed to formally examine medication taking self-efficacy as a mediator.

Using expert opinion to quantify unmeasured confounding bias parameters

OBJECTIVE: To develop and apply a method to quantify bias parameters in the case example of the association between alcohol use and HIV-serodiscordant condomless anal sex with potential confounding by sensation seeking among men who have sex with men (MSM), using expert opinion as an external data source.METHODS: Through an online survey, we sought the input of 41 epidemiologist and behavioural scientists to quantify six parameters in the population of MSM: the proportion of high sensation seeking among heavy-drinking MSM, the proportion of sensation seeking among low-level drinking MSM, and the risk ratio (RR) of the association between sensation seeking and condomless anal sex, for HIV-positive and HIV-negative MSM.RESULTS: Eleven experts responded. For HIV-positive heavy drinkers, the proportion of high sensation seeking was 53.6% (beta distribution [α = 5.50, β = 4.78]), and 41.1% (beta distribution [α = 3.10, β = 4.46]) in HIV-negative heavy drinkers. In HIV-positive low-level alcohol drinkers, high sensation seeking was 26.9% (beta distribution [α = 1.81, β = 4.92]), similar to high sensation seeking among HIV-negative low-level alcohol drinkers (25.3%) (beta distribution [α = 2.00, β = 5.89]). The lnRR for the association between sensation seeking and condomless anal sex was ln(2.4) (normal distribution [μ = 0.889, α = 0.438]) in HIV-positive and ln(1.5) (normal distribution [μ = 0.625, σ = 0.391]) in HIV-negative MSM.CONCLUSION: Expert opinion can be a simple and efficient method for deriving bias parameters to quantify and adjust for hypothesized confounding. In this test case, expert opinion confirmed sensation seeking as a confounder for the effect of alcohol on condomless anal sex and provided the parameters necessary for probabilistic bias analysis.RésuméOBJECTIF: En utilisant l’opinion d’experts comme source de données externe, élaborer et appliquer une méthode pour chiffrer les paramètres de biais dans le cas de l’association entre la consommation d’alcool et le sexe anal sans condom entre partenaires sérodifférents pour le VIH, avec un facteur de confusion possible, la recherche de sensations, chez les hommes ayant des relations sexuelles avec des hommes (HARSAH).MÉTHODE: Au moyen d’un sondage en ligne, nous avons sollicité l’opinion de 41 épidémiologistes et spécialistes du comportement pour chiffrer six paramètres dans la population des HARSAH: la proportion de chercheurs de sensations fortes chez les HARSAH grands buveurs d’alcool, la proportion de chercheurs de sensations chez les HARSAH petits buveurs d’alcool, et le risque relatif (RR) de l’association entre la recherche de sensations et le sexe anal sans condom chez les HARSAH séropositifs et séronégatifs.RÉSULTATS: Onze spécialistes ont répondu. Chez les grands buveurs séropositifs, la proportion de chercheurs de sensations fortes était de 53,6 % (distribution bêta [α =5,50, β =4,78]); elle était de 41,1 % (distribution bêta [α =3,10, β= 4,46]) chez les grands buveurs séronégatifs. Chez les petits buveurs séropositifs, les chercheurs de sensations fortes représentaient 26,9 % (distribution bêta [α =1,81, β =4,92]), ce qui est comparable aux chercheurs de sensations fortes chez les petits buveurs séronégatifs (25,3 %) (distribution bêta [α= 2,00, β =5,89]). Le logarithme du risque relatif (lnRR) de l’association entre la recherche de sensations et le sexe anal sans condom était ln(2,4) (distribution normale [μ = 0,889, σ = 0,438]) chez les HARSAH séropositifs et ln(1,5) (distribution normale [μ =0,625, σ =0,391]) chez les HARSAH séronégatifs.CONCLUSION: L’opinion d’experts peut être une méthode simple et efficace pour dériver des paramètres de biais afin de chiffrer les facteurs de confusion hypothétiques et d’apporter les ajustements nécessaires. Dans ce cas type, l’opinion d’experts a confirmé que la recherche de sensations est un facteur de confusion de l’effet de l’alcool sur le sexe anal sans condom, et cette opinion a fourni les paramètres nécessaires à une analyse du biais probabiliste.