William J. Woods

Substance use and sexual transmission risk behavior of HIV-positive men who have sex with men

We examined substance use in relationship to transmission risk behavior (unprotected insertive, UIAI, or receptive anal intercourse, URAI) between HIV-positive men who have sex with men (MSM) and their HIV-negative or unknown serostatus partners. Men who engaged in transmission risk behavior with casual partners were more likely than men who did not engage in such behavior to have used various substances. Users of certain drugs were specifically less likely to use condoms with HIV-negative or unknown status partners than users. Of men who drank alcohol, those who drank more frequently before or during sex engaged in significantly more UIAI with casual partners. Of men who used drugs, those who used more frequently before or during sex were more likely to engage in URAI with casual partners. In multivariate analyses, use of inhalants as well as drinking before or during sex predicted UIAI, while use of inhalants as well as noninjection drug use before or during sex predicted URAI. HIV prevention programs for HIV-positive MSM should focus on decreasing substance use and use specifically before or during sex. Developing prevention programs for substance-using MSM is critical to improve community health and decrease HIV transmissions.

Differential HIV Risk in Bathhouses and Public Cruising Areas

OBJECTIVES This report investigates differences in risk behaviors among men who have sex with men (MSM) who went to gay bathhouses, public cruising areas, or both. METHODS We used a probability sample of MSM residing in 4 US cities (n = 2,881). RESULTS Men who used party drugs and had unprotected anal intercourse with nonprimary partners were more likely to go to sex venues than men who did not. Among attendees, MSM who went to public cruising areas only were least likely, and those who went to both public cruising areas and bathhouses were most likely to report risky sex in public settings. CONCLUSIONS Distinguishing between sex venues previously treated as a single construct revealed a significant association between pattern of venue use and sexual risk. Targeting HIV prevention in the bathhouses would reach the segment of men at greatest risk for HIV transmission.

Illicit substance use, sexual risk, and HIV-positive gay and bisexual men: differences by serostatus of casual partners.

Objective:To examine the use of alcohol and illicit drugs among HIV-positive gay and bisexual men and to determine substance-use-related predictors of unprotected sex with casual partners who were HIV negative, HIV positive, or whose serostatus was unknown. Design:Cross-sectional assessment of baseline data from a behavioral intervention. Methods:From 1999 to 2001, we recruited 1168 HIV-positive gay and bisexual men in New York City and San Francisco and determined the prevalence of drinking and drug use, as well as the use of substances with sex. We then examined associations between substance use variables and risky sexual behaviors with casual partners by partner serostatus. Results:Substance use was common, and the use of ‘party drugs’ [e.g. methamphetamine, nitrate inhalants (poppers), ketamine, and gamma hydroxybutyrate] was most often associated with sexual risk in multivariate models. Substance use before or during sex was not associated with risk with HIV-negative partners, but was associated with risk with HIV-positive and unknown-serostatus partners. Conclusion:Substance use before or during sex was not associated with risk with HIV-negative partners, suggesting that disclosure by HIV-negative sexual partners of HIV-positive men may be important. Being a user of particular party drugs was associated with recent risk with HIV-negative partners. With partners whose serostatus was unknown, the use of certain party drugs and using substances in the context of sex was associated with risk, possibly as a result of reliance on assumptions of seroconcordance. This same pattern was seen for HIV-positive casual partners. These data have intervention implications for both HIV-positive and HIV-negative men.

Changing sexual behavior among gay male repeat testers for HIV: a randomized, controlled trial of a single-session intervention.

CONTEXT High-risk sexual behavior is increasingly prevalent among men who have sex with men (MSM) and among men with a history of repeat testing for HIV. OBJECTIVES The study assessed whether one counseling intervention session focusing on self-justifications (thoughts, attitudes, or beliefs that allow the participant to engage in high-risk sexual behaviors) at most recent unprotected anal intercourse (UAI) is effective in reducing future high-risk behaviors among HIV-negative men. DESIGN, SETTING, AND PARTICIPANTS A randomized, controlled, counseling intervention trial was conducted at an anonymous testing site in San Francisco, California, between May 1997 and January 2000. Participants were 248 MSM with a history of at least one previous negative HIV test result and self-reported UAI (receptive or insertive) in the previous 12 months with partners of unknown or discordant HIV status. Two intervention groups received standard HIV test counseling plus a cognitive-behavioral intervention, and two control groups received only standard HIV test counseling. Follow-up evaluation was at 6 and 12 months. MAIN OUTCOME MEASURE Number of episodes of UAI with nonprimary partners (of unknown or discordant HIV status) in the 90 days preceding the interview was measured via self-report during face-to-face interview. RESULTS A novel counseling intervention focusing on self-justifications significantly decreased the proportion of participants reporting UAI with nonprimary partners of unknown or discordant HIV status at 6 and 12 months (from 66% to 21% at 6 months and to 26% at 12 months, p =.002; p <.001) as compared with a control group when added to standard client-centered HIV counseling and testing. CONCLUSIONS A specific, single-session counseling intervention focusing on a reevaluation of a persons self-justifications operant during a recent occasion of high-risk behavior may prove useful in decreasing individual risk behavior and thus limiting community-level HIV transmission.

Evaluating needle exchange: are there negative effects?

ObjectiveWe analyzed data on all drug-treatment admissions in San Francisco County over a 4-year period (n = 35460) to evaluate the potential negative effects of the San Francisco needle-exchange program. MethodsAdmissions in the 2 years preceding implementation of the exchange program (1987–1988) were compared with admissions in the 2 years following implementation (1989–1990). ResultsNo negative consequences of needle exchange were detected. Specifically, the presence of the exchange program was not associated with (1) increases in injection drug use, (2) increases in needle-sharing behavior, or (3) changing drug-use behavior from non-injection to injection. We also compared high-drug-use neighborhoods with and without local needle-exchange sites. Neighborhoods without needle-exchange sites showed a greater increase in proportion of admissions for injection drug use, and in frequency of injection, over time. ConclusionsBecause of methodological limitations, our findings are preliminary. Longitudinal studies comparing needle-exchange and non-exchange cohorts are needed to further evaluate effects of this intervention.

Brief cognitive counseling with HIV testing to reduce sexual risk among men who have sex with men: results from a randomized controlled trial using paraprofessional counselors.

Objectives:To test the efficacy and acceptability of a single-session personalized cognitive counseling (PCC) intervention delivered by paraprofessionals during HIV voluntary counseling and testing. Methods:HIV-negative men who have sex with men (MSM; n = 336) were randomly allocated to PCC or usual counseling (UC) between October 2002 and September 2004. The primary outcome was the number of episodes of unprotected anal intercourse (UAI) with any nonprimary partner of nonconcordant HIV serostatus in the preceding 90 days, measured at baseline, 6 months, and 12 months. Impact was assessed as “intent to treat” by random-intercept Poisson regression analysis. Acceptability was assessed by a standardized client satisfaction survey. Results:Men receiving PCC and UC reported comparable levels of HIV nonconcordant UAI at baseline (mean episodes: 4.2 vs. 4.8, respectively; P = 0.151). UAI decreased by more than 60% to 1.9 episodes at 6 months in the PCC arm (P < 0.001 vs. baseline) but was unchanged at 4.3 episodes for the UC arm (P = 0.069 vs. baseline). At 6 months, men receiving PCC reported significantly less risk than those receiving UC (P = 0.029 for difference to PCC). Risk reduction in the PCC arm was sustained from 6 to 12 months at 1.9 (P = 0.181), whereas risk significantly decreased in the UC arm to 2.2 during this interval (P < 0.001 vs. 6 months; P = 0.756 vs. PCC at 12 months). Significantly more PCC participants were “very satisfied” with the counseling experience (78.2%) versus UC participants (59.2%) (P = 0.002). Conclusions:Both interventions were effective in reducing high-risk sexual behavior among MSM repeat testers. PCC participants demonstrated significant behavioral change more swiftly and reported a more satisfying counseling experience than UC participants.

Psychosocial correlates of transmission risk behavior among Hiv-seropositive gay and bisexual men

Objectives:We sought to identify the determinants of sexual transmission risk behavior by HIV-positive individuals. We examined social cognitive theory (SCT) variables, which have been found to mediate the effectiveness of HIV risk reduction interventions. We also sought to identify contextual influences that might contribute to initial levels of SCT factors such as self-efficacy. Method:In the present study, a series of social cognitive variables and a number of factors hypothesized to influence self-efficacy were assessed among participants at baseline in the Seropositive Urban Mens Intervention Trial. Variables tested for their effects on self-efficacy included hedonistic and self-evaluative outcome expectancies, sexual compulsivity, a history of childhood sexual abuse, drug use, and race. Models predicting condom use during anal sex with partners of HIV-negative or unknown status were tested separately for main partners and for non-main partners. Results:Self-efficacy was associated with condom use in both analyses. Contextual influences on condom use with main partners were fewer and operated mostly via effects on self-efficacy. Influences on condom use with non-main partners exerted both direct effects on condom use and effects mediated by self-efficacy. Drug use was predictive of condom use with non-main, but not main, partners. Discussion:The present results support the approach of addressing both standard SCT factors, and when possible contextual factors in interventions for HIV-positive men.

Predictors of the use of viagra, testosterone, and antidepressants among HIV-seropositive gay and bisexual men

Objective:To examine the use and correlates of the use of prescription drugs that may affect sexual behavior among HIV-positive gay and bisexual men. Methods:In a cross-sectional assessment of baseline data from a behavioral intervention, we recruited 1168 HIV-positive gay and bisexual men in 2000–2001 from community venues in New York City and San Francisco, and determined the point prevalence of the use of viagra, testosterone, and antidepressants. We examined bivariate and multivariate associations between the use of each drug and demographics, health status, substance use, psychological symptoms, and sexual risk. Results:The current use of antidepressants was 21%, testosterone 19%, and viagra 12%. Some viagra users reported using drugs that could interact dangerously with viagra. The use of viagra, testosterone, or antidepressants was related to unprotected receptive anal intercourse and unprotected insertive oral intercourse (UIOI) with both HIV-positive and HIV-negative/unknown-status casual partners. The use of viagra was also associated with unprotected insertive anal intercourse. In multivariate models, viagra use was associated with being older, more educated, using ketamine, and engaging in UIOI with HIV-negative/unknown-status casual partners. Testosterone use was associated with being more educated and using nitrites (poppers). Antidepressant use was associated with race, using poppers, and being more depressed. Conclusion:Prescription medications used by HIV-positive men can have unintended negative effects such as drug interactions or associations with risky sexual behavior, particularly a drug such as viagra that is fast acting, short lasting, and provides a desirable effect. Physicians should discuss these issues with patients when prescribing, and interventions should address these challenges.

Changes in needle sharing behavior among intravenous drug users: San Francisco, 1986-88.

We analyzed data for San Francisco intravenous drug users entering treatment, April 1986-September 1988 (N = 7,660). The proportion of cases reporting any needle sharing in the month preceding treatment decreased from 50 percent in 1986 to 28 percent in 1988. Similar decreases were reported by two longitudinal cohorts (needle sharing by the same individuals) admitted in 1986 and 1987 (n = 303), and in 1986 and 1988 (n = 205). In a multiple logistic regression model four variables predicted needle sharing: earlier time of admission, cocaine use, younger age, and being White rather than Black.

Changes in HIV-related behaviors among heterosexual alcoholics following addiction treatment

In order to measure changes in HIV-related behaviors among heterosexual alcoholics following treatment, we conducted a prospective cohort study of 700 self-identified alcoholics recruited from five public alcohol treatment centers, all of which included HIV risk-reduction counseling. Respondents underwent an HIV antibody test and interviewer-administered questionnaire at entry to alcohol treatment and after a mean of 13 months later. Compared to baseline, at follow-up there was an overall 26% reduction in having sex with an injection-drug-using partner (23% versus 32%, P < .001) and a 58% reduction in the use of injection drugs (15% versus 37%, P < .001), along with smaller improvements in other behaviors. Respondents also showed a 77% improvement in consistent condom use with multiple sexual partners (35% versus 20%, P < .01) and a 23% improvement in partner screening (71% versus 57%, P < .001). Respondents who remained abstinent showed substantially greater improvement than those who continued to drink.