Susan A. Stoner

Alcohol use and antiretroviral adherence: Review and meta-analysis

Background:Alcohol use is frequently implicated as a factor in nonadherence to highly active antiretroviral therapy (HAART). There have not been efforts to systematically evaluate findings across studies. This meta-analysis provides a quantitative evaluation of the alcohol-adherence association by aggregating findings across studies and examining potential moderators. Methods:Literature searches identified 40 qualifying studies totaling over 25,000 participants. Studies were coded on several methodological variables. Results:In the combined analysis, alcohol drinkers were approximately 50%-60% as likely to be classified as adherent [odds ratio (OR) = 0.548, 95% confidence interval (CI): 0.490 to 0.612] compared with abstainers (or those who drank relatively less). Effect sizes for problem drinking, defined as meeting the National Institute on Alcohol Abuse and Alcoholism criteria for at-risk drinking or criteria for an alcohol use disorder, were greater (OR = 0.474, 95% CI = 0.408 to 0.550) than those reflecting any or global drinking (OR = 0.604, 95% CI = 0.531 to 0.687). Several variables moderated the alcohol-adherence association. Conclusions:Results support a significant and reliable association of alcohol use and medication nonadherence. Methodological variables seem to moderate this association and could contribute to inconsistent findings across studies. Future research would benefit from efforts to characterize theoretical mechanisms and mediators and moderators of the alcohol-adherence association.

Understanding acute alcohol effects on sexual behavior

Abstract Alcohol has been implicated as having a causal role in a variety of sexual processes and outcomes. We review nonexperimental research illustrating the nature of alcohols association with sexuality. Methodological considerations limiting causal assertions permissible with nonexperimental data are discussed. We also review findings from experiments, mostly analogue paradigms, examining the effects of alcohol on genital arousal, sexual risk taking, and sexual assault. In each case, it is observed that alcohol can exert a causal effect on one or more of the constituent responses undergirding these phenomena. We conclude that alcohol does appear to have a causal impact on many sexuality indices studied in laboratory conditions. Both alcohol expectancy and alcohol myopia models have been applied to explain these causal linkages. Expectancy models seem to account well for postdrinking sexual reactions and perceptions. Overall, myopia analyses seem to offer the most persuasive explanations of postdrinking expressions of sexual risk taking and sexual assault.

Indirect Effects of Acute Alcohol Intoxication on Sexual Risk-taking: The Roles of Subjective and Physiological Sexual Arousal

Three experiments supported the idea that alcohol fosters sexual risk-taking in men and women, in part, through its effects on sexual arousal. In Experiment 1, increasing alcohol dosage (target blood alcohol levels of .00, .04, .08%) heightened men’s and women’s risk-taking intentions. Alcohol’s effect was indirect via increased subjective sexual arousal; also, men exhibited greater risk-taking than women. In Experiment 2, an extended dosage range (target blood alcohol levels of .00, .06, .08, .10%) heightened men’s risk-taking intentions. Alcohol’s effect again was indirect via subjective arousal. Physiological sexual arousal, which was unaffected by alcohol, increased risk-taking via increased subjective arousal. In Experiment 3, alcohol increased women’s risk-taking indirectly via subjective arousal, but alcohol-attenuated physiological arousal had no effect on risk-taking. Implications for alcohol myopia theory and prevention interventions are discussed.

Alcohol use, expectancies, and sexual sensation seeking as correlates of HIV risk behavior in heterosexual young adults.

Most theoretical models of HIV risk behavior have not considered the role of personality factors, and few studies have examined mechanisms accounting for dispositional influences on sexual risk taking. This study elaborated on a conceptual model emphasizing sexual sensation seeking, alcohol expectancies, and drinking before sex as key predictors of HIV risk (S. C. Kalichman, L. Tannenbaum, & D. Nachimson, 1998). Multiple groups structural equation modeling was used to determine whether gender moderated relationships among these variables in a sample of 611 heterosexual, young adult drinkers (49% women, 76% Caucasian, mean age = 25 years). The model provided an excellent fit to the data, and gender differences were not substantiated. Sexual sensation seeking predicted HIV risk directly as well as indirectly via sex-related alcohol expectancies and drinking in sexual contexts. Findings suggest that expectancies and drinking before sex represent proximal mechanisms through which dispositional factors influence sexual risk outcomes. Moreover, these relationships appear to be similar in men and women. Interventions could benefit from targeting alcohol expectancies and drinking before sex in individuals with a dispositional tendency toward sexual risk taking.

An online self-help CBT intervention for chronic lower back pain

ObjectivesResearch has shown that cognitive and behavioral therapies can effectively improve quality of life in chronic pain patients. Unfortunately, many patients lack access to cognitive and behavioral therapy treatments. We developed a pilot version of an interactive online intervention to teach self-management skills for chronic lower back pain, a leading cause of disability and work absenteeism. The objective of this randomized, controlled trial was to evaluate its efficacy. MethodsIndividuals with chronic lower back pain were recruited over the Internet, screened by phone, and randomly assigned to receive access to the intervention (Wellness Workbook; WW) either immediately (intervention group) or after a 3-week delay (wait-list control). Participants (n=141, 83% female, 23% minority) were asked to complete the WW over 3 weeks. Self-report measures of pain, disability, disabling attitudes and beliefs, self-efficacy for pain control, and mood regulation were completed at baseline, week 3, and week 6. ResultsControlling for baseline individual differences in the outcome measures, multivariate analysis of covariance revealed that, at week 3, the intervention group scored better than the wait-list control group on all outcomes, including pain severity ratings. At week 6, after both groups had been exposed to the WW, there were no differences between groups. DiscussionUse of this pilot intervention seems to have had positive effects on a number of pain-related outcomes, including disability. Future research will evaluate the effectiveness of the completed intervention, with particular attention to quality of life and disability.

Women's condom use assertiveness and sexual risk-taking: Effects of alcohol intoxication and adult victimization

This experiment examined relationships among adulthood victimization, sexual assertiveness, alcohol intoxication, and sexual risk-taking in female social drinkers (N=161). Women completed measures of sexual assault and intimate partner violence history and sexual assertiveness before random assignment to 1 of 4 beverage conditions: control, placebo, low dose (.04%), or high dose (.08%). After drinking, women read a second-person story involving a sexual encounter with a new partner. As protagonist of the story, each woman rated her likelihood of condom insistence and unprotected sex. Victimization history and self-reported sexual assertiveness were negatively related. The less sexually assertive a woman was, the less she intended to insist on condom use, regardless of intoxication. By reducing the perceived health consequences of unprotected sex, intoxication indirectly decreased condom insistence and increased unprotected sex. Findings extend previous work by elucidating possible mechanisms of the relationship between alcohol and unprotected sex - perceived health consequences and situational condom insistence - and support the value of sexual assertiveness training to enhance condom insistence, especially since the latter relationship was robust to intoxication.

Women’s Awareness of and Discomfort With Sexual Assault Cues Effects of Alcohol Consumption and Relationship Type

Two studies examined the effects of alcohol and relationship type on women’s sexual assault risk perception. Study 1 participants (N = 62) consumed a moderate alcohol dose or nonalcoholic beverage, then rated their awareness of and discomfort with sexual assault risk cues in a hypothetical encounter with a new or established dating partner. Study 2 (N = 351) compared control, placebo, low, and high alcohol dose conditions using a similar scenario. Intoxicated women reported decreased awareness of and discomfort with risk cues. An established relationship decreased discomfort ratings. Findings indicate that alcohol may increase women’s sexual victimization likelihood through reduced sexual assault risk perception.

Effects of Alcohol Intoxication and Victimization History on Women's Sexual Assault Resistance Intentions: The Role of Secondary Cognitive Appraisals

This study used an experimental paradigm to investigate the role of secondary cognitive appraisals in womens sexual assault resistance and whether these appraisals mediated influences of alcohol and prior victimization. After consuming a beverage (control, placebo, moderate, or high dose), 351 women projected themselves into a simulated interaction with a sexually aggressive man. Four types of secondary appraisals (shock at the mans behavior, concern about his feelings, uncertainty in the situation, conflict about what to do) and three resistance strategies (assertive, polite, passive) were examined. Path modeling revealed that, as expected, intoxication and prior sexual victimization influenced secondary appraisals, which in turn influenced intended resistance. Prior adult sexual assault (ASA) and childhood sexual abuse (CSA) also had direct effects: ASA negatively predicted assertive resistance and CSA positively predicted passivity. Findings suggest that secondary appraisals are key targets for intervention to facilitate effective resistance, thereby reducing the risk of adult sexual victimization.

Influences of sexual sensation seeking, alcohol consumption, and sexual arousal on women's behavioral intentions related to having unprotected sex.

This experimental study examined effects of alcohol consumption and sexual sensation seeking on unprotected sex intentions, taking into account sexual arousal, indirectly discouraging sex, and condom insistence. Women (N = 173; mean age = 25.02) were randomly assigned to a control, placebo, low-dose beverage (target blood alcohol level = .04), or high- dose beverage (target blood alcohol level = .08) condition. Participants projected themselves into a hypothetical sexual interaction with a man in which no condom was available. Structural equation modeling demonstrated that both sexual sensation seeking and alcohol dose directly increased sexual arousal early in the interaction, but later sexual arousal indirectly increased unprotected sex intentions by decreasing endorsement of indirect discouragement and, in turn, condom insistence. These findings help to clarify the role of alcohol consumption and sensation seeking in womens sexual decision making and point to the importance of examining it as a multistage process. (PsycINFO Database Record (c) 2009 APA, all rights reserved).

Cognitive Mediation of Alcohol’s Effects on Women’s In-the-Moment Sexual Decision Making

OBJECTIVE To test a cognitive mediation model examining whether cognitive appraisals mediate alcohol consumption effects on condom request and unprotected sex intentions. DESIGN Female social drinkers (N = 173) participated in an experiment comparing four beverage conditions: control, placebo, target BAL = .04%, and target BAL = .08%. Subjects projected themselves into a hypothetical sexual encounter with a new sex partner. MEASURES Appraisals of the situations sexual potential, impelling and inhibiting cognitions, and behavioral intentions were assessed at several points. RESULTS Findings support the theoretical model, indicating that alcohols effects on direct condom request and unprotected sex intentions were mediated through cognitive appraisals. CONCLUSION Prevention interventions should include information about alcohols effects on cognitions that may lead to ineffective condom negotiation and unprotected sex.