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. Author manuscript; available in PMC: 2015 Jul 1.
Published in final edited form as: Drug Alcohol Depend. 2015 Apr 30;152:109–115. doi: 10.1016/j.drugalcdep.2015.04.011

Daily Co-Occurrence of Alcohol Use and High-Risk Sexual Behavior among Heterosexual, Heavy Drinking Emergency Department Patients

Tyler B Wray 1, Mark A Celio 1, Christopher W Kahler 1, Nancy P Barnett 1, Nadine R Mastroleo 1, Don Operario 1, Peter M Monti 1
PMCID: PMC4458208  NIHMSID: NIHMS687135  PMID: 25962789

Abstract

Background

Global association and experimental studies suggest that alcohol use may increase sexual behavior that poses risk for exposure to sexually-transmitted infections (STI) among heterosexual men and women. However, results from longitudinal and daily recall studies exploring the co-occurrence of alcohol use with various sexual risk outcomes in more naturalistic contexts have been mixed, and the bulk of this research has focused on college students.

Methods

The current study enrolled heavy-drinking emergency department (ED) patients and used a cross-sectional, 30-day Timeline Followback (TLFB) method to examine the daily co-occurrence between alcohol use and three sexual behavior outcomes: Any sex, unprotected intercourse (UI), and UI with casual partners (vs. protected intercourse [PI] with casual partners, or UI/PI with steady partners).

Results

Results indicated that increasing levels of alcohol use on a given day increased the odds of engaging in any sexual activity and that heavy drinking (but not very heavy drinking) on a given day was associated with an increased odds of engaging in UI with either steady or casual partners. However, day-level alcohol use was not associated with an increased odds of UI with casual partners.

Conclusions

These findings suggest that alcohol may play an important role in increasing risk for HIV/STIs among heterosexuals, and support the continued need to target heavy drinking in sex risk reduction interventions. However, our results also suggest that alcohol may not universally result in unprotected sex with casual partners, a behavior posing perhaps the highest risk for HIV/STI transmission.

Keywords: Alcohol, heavy drinking, sex risk, unprotected sex

1. Introduction

Unsafe sex (i.e., unprotected sex that could lead to sexually transmitted infections [STI] and/or unintended pregnancies) is a significant cause of disease and disability (Glasier et al., 2006). Indeed, 6.2% of all disability-adjusted life years is attributable to unprotected sexual behavior in the United States (Ebrahim et al., 2005), and the annual direct medical costs associated with STIs topped $15.6 billion dollars in 2008 (Owusu-Edusei Jr et al., 2013). The resurgence of previously well-controlled STIs (e.g., syphilis; Mattei et al., 2012) and growing treatment resistance (CDC, 2013) suggest that STI-related burden may grow substantially in the near future, highlighting the importance of research into factors contributing to unsafe sex.

Alcohol use has been implicated as a key factor in the spread of STIs (Cook and Clark, 2005; Schneider et al., 2012), due in part to findings from cross-sectional (Grossman and Markowitz, 2005; Sen, 2002) and experimental findings (Rehm et al., 2012) supporting a relationship between alcohol use and unsafe sex. However, design limitations of these studies prevent conclusive inferences about the alcohol-unsafe sex link. Cross-sectional studies focusing on overall involvement in alcohol use and sexual risk (e.g., “over the past 6 months”) cannot establish the temporal proximity of the two behaviors. Moreover, experimental studies examine unprotected sex intentions using hypothetical scenarios. While there is evidence that intentions to use condoms are a robust predictor of condom use (Albarracin et al., 2001; Reinecke et al., 1996), important differences may exist between intentions rated in laboratory settings and real world behavior.

Situational association studies address these limitations by exploring whether alcohol use co-occurs with unsafe sex on the same occasion in naturalistic contexts. Early meta-analyses of event-level studies found that alcohol appeared to be unrelated to increased unsafe sex (Leigh, 2002; Weinhardt and Carey, 2000), but most of these studies explored their co-occurrence on just a few occasions (e.g., first sex, last sex). Studies utilizing more intensive assessments (e.g., cross-sectional daily recall or longitudinal designs) have the potential to explore whether alcohol and unsafe sex co-occur across many days, drinking occasions, and sex events over a given time period. Several such studies have been conducted since the aforementioned meta-analyses were published, and suggest that alcohol use consistently increases the likelihood of sex, but that the use of protection may depend on partner factors. For example, one daily diary study (Kiene et al., 2009) and two studies using situation and day-level recall assessments (Brown and Vanable, 2007; LaBrie et al., 2005) showed that drinking increased the odds of unprotected sex specifically with casual partners. However, at least one daily recall study found the opposite. Heavy drinking was associated with unprotected sex only with steady partners, and this relationship was significant only among women (Scott-Sheldon et al., 2010b). Moreover, one daily diary study found that alcohol use was not associated with condom use (Morrison et al., 2003). As such, while situational association studies are critical to understanding whether alcohol use increases unsafe sex in the real world, findings from these studies have been mixed. The vast majority of these studies have also focused on adolescents and college students. Although this may be warranted because of elevated STI risk among young adults (CDC, 2012), few studies have explored the alcohol-unsafe sex link in a broader range of adults or among those who drink heavily. Hence, findings from past studies on this link may be difficult to generalize beyond college students and young adults.

This study addresses this gap in the literature by examining the day-level co-occurrence between alcohol use level and sexual behavior in a sample of heavy-drinking emergency department patients who have engaged in some sexual risk behavior in the past 3 months (i.e., unprotected sex with a casual partner or unprotected sex with a steady partner who’s fidelity is questioned or known). We used a cross-sectional daily assessment method (Timeline Followback [TLFB]) to explore the association between alcohol use level and three key sex outcomes on a given day: The occurrence of (1) any sex, (2) unprotected intercourse (UI) with either steady or casual partners (vs. protected intercourse [PI]), and (3) UI with a casual partner (vs. “safer” forms of sex, such as PI with casual partners and/or UI/PI with a steady partner). These three variables allowed us to examine the association of alcohol use with engaging in any sex at all versus sex that is associated with increasing levels of risk. Given our study inclusion criteria, UI with any type of partner conveys some risk. However, because this outcome includes UI with steady partners, the risk for STI transmission may be lower for this outcome, since it may be more likely to involve risk reduction efforts other than condom use (e.g., sexual exclusivity, discussion of sexual history and STI status, use of alternative methods of contraception). UI with casual partners (vs. PI with a casual partner or PI/UI with a steady partner), however, likely conveys the highest risk of the three. Based on past findings (e.g., Brown and Vanable, 2007; Kiene et al., 2009; LaBrie et al., 2005; Morrison et al., 2003), we hypothesized that higher levels of alcohol use, specifically use indicative of intoxication (i.e., consuming 5–11, or 12+ drinks on a given day for men, or 4–9, or 10+ drinks for women) would be uniquely associated with an increased odds of engaging in UI with casual partners versus engaging in “safer” forms of sex.

2. Materials and Methods

This study used baseline data from 371 patients seeking medical treatment in the ED who enrolled in a randomized trial of a brief, combined intervention for alcohol and sex risk. This broader study explored whether a brief, motivational interviewing intervention could reduce heavy drinking and sexual risk behavior compared with brief advice. Inclusion criteria were: (1) Scores > 8 for men and > 6 for women on the Alcohol Use Disorders Identification Test (AUDIT; Babor et al., 2001) or ≥ 1 episode of binge drinking (5+ drinks for males; 4+ for females) in the past 3 months; and (2) reporting unprotected sex or using alcohol/drugs prior to or during sex during the past 3 months with either a casual partner or a steady partner where infidelity was questioned or known. Patients in a mutually monogamous relationship for > 6 months were excluded.

Nine percent of participants reported being bisexual (87.9% women, 12.1% men), 1.6% were gay, 1.6% were lesbian, and 1.1% reported being “not sure” about their sexual orientation. Since factors affecting sexual decision-making among these participants are likely unique (Beyrer et al., 2012; Earl and Albarracín, 2007), we chose to exclude them from the present analyses. Excluding these participants, one transgender participant, and one HIV+ participant resulted in a final sample of 322.

All procedures were approved by university and hospital Institutional Review Boards. Project staff worked on-site in the EDs to identify eligible patients and explain the study. Screening took place with the permission of medical staff and in-between medical care. A mini mental status exam and breathalyzer reading were administered to ensure patients were able to provide informed consent (i.e., the patient was oriented, able to concentrate, and able to understand and remember the requirements of the study).

After informed consent, participants completed most measures using a laptop computer. TLFB measures were collected in interview format to ensure accuracy. Completion of all study measures took 45–60 minutes.

2.1. Measures

2.1.1. Screening measures

Heavy/problematic alcohol use was assessed using the AUDIT, a 10-item questionnaire (Babor et al., 2001). Scores ≥ 8 for males (Conigrave et al., 1995), and ≥ 6 for females (Reinert & Allen, 2002) were used as inclusion criteria. Sexual risk inclusion criteria were assessed using items on HIV/STI risk from past research (Kalichman et al., 1998; Millstein and Moscicki, 1995), including total number of sex partners, frequency of unprotected sex (vaginal or anal), and frequency of alcohol/drug consumption before or during sex in the past 3 months. Demographic characteristics were collected via online questionnaire.

2.2.2. Study measures

Daily alcohol use, drug use, and sexual behaviors were assessed using Timeline Followback (TLFB; Carey et al., 2001; Sobell et al., 1980). Participants reported the number of standard drinks (12 oz. beer, 5 oz. wine, 1.5 oz. of liquor) consumed, and whether marijuana or “other” drugs were used, for each day of the 30 days prior to baseline. Recall accuracy was enhanced by using a calendar and identifying “important dates” for each participant. The TLFB has demonstrated excellent reliability and validity when assessing alcohol and drug use (Fals-Stewart et al., 2000; Sobell and Sobell, 1980; Sobell et al., 1979; Sobell and Sobell, 1979).

The TLFB also assessed sexual behavior on each day, collecting information about partner type (regular vs. casual) and gender, specific sexual activities performed (vaginal, insertive or receptive anal sex), whether sex took place under the influence of alcohol only, drugs only, or both, and whether a condom was used. TLFBs for sexual behavior have been shown to be reliable and valid (Carey et al., 2001; Napper et al., 2010; Weinhardt et al., 1998; Wray et al., in press). Participants were also asked to indicate whether each sex act occurred with a “regular” partner or “casual” partner. “Regular” partners were defined as someone with whom they were in a “romantic, committed relationship with for at least the past 3 months,” and all other partners were coded as “casual.” Participants could specify having multiple partners on a given day, and binary indicators were coded for each type of sexual behavior (e.g., unprotected vaginal/anal sex with a casual partner) on a given day.

2.2. Analysis Plan

We examined daily associations between static and time-varying variables and the occurrence of three types of sexual behaviors: (1) Any vaginal or anal intercourse (insertive or receptive) vs. no sex, (2) unprotected vaginal or anal intercourse (UI) vs. PI (regardless of partner type), and (3) UI with a casual partner vs. PI with a casual partner or UI/PI with a steady partner. Since this final outcome was only relevant for those reporting sex with a casual partner, we restricted this model to these individuals. A four-level, time-varying term was generated to examine the linear effects of alcohol use on a given day and was adjusted for gender. For men: (0) 0 drinks, (1) 1–4 drinks, (2) 5–11 drinks, and (3) 12+ drinks. For women: (0) 0 drinks, (1) 1–3 drinks, (2) 4–9 drinks, and (3) 10+ drinks. These reference groups were chosen to align with NIAAA’s definitions of “heavy drinking” (5+ for men, 4+ for women), as these levels pose higher risks for alcohol-related problems (NIAAA, 2005). The heaviest drinking category (12+ for men, 10+ for women) was chosen given evidence that, for men who drink heavily on average (i.e., 5–12 drinks), 12+ drinks on a given day confers additional risk for alcohol-related problems beyond drinking at “binge” (5+ drinks) levels (Greenfield et al., 2014). The value of the very heavy drinking category for women (10+) was derived by extending gender differences in lower drinking categories (4+/5+) to the highest category. We also tested potential quadratic associations between alcohol use on a given day and sex outcomes. Both linear and quadratic alcohol use terms were centered prior to analysis. If the alcohol use term was significant, we ran separate models to test pairwise odds ratios for each drinking category compared to no drinking.

Given that TLFB data produces cross-sectional, time-series data, we used generalized estimating equations (GEEs) in Stata 13 (Stata Corp., 2013) to account for correlations between reports within subjects (Zeger and Liang, 1986; Zeger et al., 1988). Given the binary nature of all outcomes, binomial distributions with logit link functions were specified. We used a “build up” strategy for including static and time-varying variables in a final model. Past studies have shown that age (e.g., Brown and Vanable, 2007) and gender (e.g., Scott-Sheldon et al., 2010a) are important covariates, so these were added in initial models testing person-level, static covariates. Additional covariates reflecting the average number of drinks per drinking day and the percentage of drug use days across the 30-day TLFB were also added to distinguish between the effects of overall alcohol and drug use involvement and drinking/drug use on a specific day on outcomes. To statistically control for potential differences across participants who engaged in sex only with steady partners and those who had casual partners during the recall period, a binary indicator representing “steady partners only” was also included. In the second model, time-varying linear and quadratic terms for alcohol use on a given day were tested. Finally, we entered time-varying terms for marijuana and other drug use on a given day to explore whether alcohol terms remained significant above-and-beyond drug use.

3. Results

3.1. Descriptive Statistics

See Table 1 for demographics. Although the demographic characteristics of ED patients meeting criteria for “hazardous drinking” varies considerably across studies, fewer participants in our sample were married (likely due to our sexual risk eligibility criterion) but were otherwise similar to past studies conducted in EDs (e.g., Cherpitel, 1995; Neumann et al., 2004). TLFB data were entirely complete, with 0% of days missing. Thus, participants provided 9,660 person-days of data across the 30-day recall period. Sex occurred on a total of 2,982 days (30.9% of days), and participants reported a mean of 9.3 (SD = 8.6) sex days in this window. Of these sex events, 81.6% (2,434) were unprotected. Fifty-six percent of participants reported having sex with only steady partners, and 33.8% reported sex with only casual partners. Among those participants reporting any sex with casual partners in the 30 days, 61.0% (741) of days involved sex with a casual partner. Of all sex days, 96.0% involved vaginal intercourse only, and 3.5% involved vaginal and anal intercourse.

TABLE 1.

Demographic and descriptive characteristics of the analyzed sample (N = 321)

Characteristics Mean (SD)
or N (%)
Age (Range: 18 – 60, M ± SD) 29.6 (9.5)
Gender
 Female 162 (50.3)
 Male 160 (49.7)
Race
 White 257 (80.1)
 Black or African American 43 (13.4)
 American Indian/Alaska Native 16 (5.0)
 Asian 1 (0.3)
 Pacific Islander 1 (0.3)
Ethnicity (Hispanic or Latino) 43 (13.4)
Marital Status
 Single/Never married 182 (56.7)
 In a committed relationship 61 (19.0)
 Divorced 22 (6.9)
 In a domestic partnership 19 (5.9)
 Separated 17 (5.3)
 Married 12 (3.7)
 Widowed 6 (1.9)
 Other 2 (0.6)
Education
 Grade school 4 (1.3)
 Some high school 52 (16.2)
 High school diploma/GED 121 (37.7)
 Some college education 81 (25.2)
 Technical or business school 10 (3.1)
 Two-year college 21 (6.5)
 Four-year college 29 (9.0)
 Master’s degree 3 (0.9)
Employment status
 Unemployed 127 (39.6)
 Part-time 70 (21.8)
 Full-time 99 (30.8)
 Full-time student 11 (3.4)
 Part-time student 8 (2.5)
 Home maker 5 (1.6)
 Retired 1 (0.3)
Income
 $0 – $29,999 205 (64.3)
 $30,000 – $59,999 77 (24.1)
 $60,000 – $89,000 28 (8.8)
 $90,000+ 9 (2.8)
% AUDIT Score ≥ 8 177 (55.14)
Total # of drinking days 177 (55.14)
% Marijuana users 9.7 (12.7)
Average # of marijuana use days 50 (15.6)
% Drug users 1.1 (4.3)
Average # of drug use days
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Participants reported drinking on 2,830 (29.3%) of the days assessed. Participants drank an average of 8.7 (SD = 7.1) out of 30 days (29.1% of days), with a mean of 7.4 (SD = 6.4) drinks per drinking day. They reported an average of 5.8 (SD = 7.1) heavy drinking days. Forty-nine percent of participants reported very heavy drinking on at least one day (for men, 12+ drinks; for women, 10+ drinks), and among these very heavy drinkers, an average of 2.2 (SD = 5.1) such days were reported. Forty-two percent of days on which sexual intercourse occurred were days on which drinking also occurred, 42.3% of days on which UI occurred were drinking days, and 52.2% of days on which UI with a casual partner occurred were drinking days.

3.2. Daily Models of Sexual Behavior

Table 2 shows descriptive statistics and pairwise correlations among person-level variables. Although unprotected sex is subsumed under the “any vaginal or anal sex” variable, the latter reflects a broader number of events. While these variables are expectedly correlated, at least 14% of the variance is independent of the other.

TABLE 2.

Pairwise correlations for individual-level variables

Variables M SD Range 1 2 3 4 5 6 7
1. Total # of any vaginal or anal sex 9.32 8.63 0–30
2. Total # UI events 7.56 8.49 0–30 0.86*
3. Total # UI w/ casual partner 2.30 5.58 0–30 0.38* 0.45*
4. Gender 162F/160M 0.07 0.09 0.07*
5. Age 29.59 9.47 18–60 0.01 0.01 −0.03* −0.05
6. Average drinks/drinking day 7.38 6.42 1–22 0.09 0.13* 0.10 0.01 −0.01
7. % of other drug use days 3.64 14.14 0–100 −0.03 −0.02* 0.05 −0.04 0.08 0.06
8. Steady partners only 165Y/157N 0.14* 0.16* −0.45* −0.03 0.10 −0.08 −0.08
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*

Note. p < .05. UI = unprotected intercourse. Sexual behavior variables reflect the total number of days reported involving each across the 30-day assessment period.

3.2.1. Any sexual intercourse

In Model 1 of time-invariant terms, reporting sex with only steady partners during the 30-day period was positively associated with the odds of having any intercourse on a given day, and this association remained significant in later models (Table 3, column 1). In Model 2, level of alcohol use on a given day was positively associated with the odds of engaging in any intercourse, and this relationship appeared to be quadratic. Comparing incrementally increasing alcohol use level categories against the reference group (no drinking) confirmed this effect (see Figure 1), suggesting that the relationship is slightly concave with the greatest increases occurring from no drinking to the lowest drinking category and leveling off as drinking increased. Compared to non-drinking days, the odds of engaging in any intercourse was 0.7 times higher when drinking was at the lowest category (men: 1–4 drinks, women: 1–3 drinks; p < .001), 0.9 times higher when above binge levels (men: 5–11, women: 4–9; p < .001), and 1.1 times higher at very high levels (men: 12+, women: 10+; p < .001). Entering time-varying drug use terms for marijuana and other drug use (Model 3) did not change the effects of alcohol, but day-level marijuana use was also positively associated with the odds of any sex.

TABLE 3.

Generalized Estimating Equations (GEE) for daily reports of engaging in any sexual intercourse (vaginal or anal), unprotected intercourse (UI), and UI with a casual partner

Any sexual intercourse
(N = 322)
UI1
(N = 322)
UI with a casual partner2
(N = 144)
Variable OR SE p OR SE p OR SE p
Model 13
 Gender 1.21 0.18 .159 1.61 0.43 .077 1.84 0.55 .042
 Age 1.00 0.01 .765 1.02 0.02 .206 1.01 0.02 .569
 Avg.drinks/drink day4 1.02 0.01 .207 1.08 0.03 .013 1.01 0.03 .687
 % drug use days4 0.99 0.01 .195 1.02 0.01 .255 1.02 0.01 .142
 Steady partners only 1.57 0.23 .002 2.08 0.54 .005 – – –
Model 2
 Daily alcohol use6 1.41 0.06 <.001 1.03 0.04 .557 1.03 0.08 .667
 Daily alc use (quad) 0.85 0.04 <.001 0.92 0.03 .028 1.02 0.08 .745
Model 3
 Daily alcohol use 1.39 0.06 <.001 1.03 0.04 .557 1.03 0.08 .697
 Daily alc use (quad) 0.85 0.04 <.001 0.92 0.03 .028 1.02 0.08 .767
 Daily marijuana use 1.45 0.17 .002 1.06 0.15 .658 1.20 0.28 .425
 Daily other drug use 1.50 0.41 .138 0.97 0.14 .839 0.70 0.21 .245
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Note. OR = Odds ratio, SE = Standard error.

1

Versus any protected intercourse (vaginal or anal), regardless of partner type.

2

Versus protected intercourse (vaginal or anal) with a casual partner or unprotected intercourse with a regular partner. Restricted to only participants reporting any casual sex during the 30-day period (N = 157).

3

Values are final model values.

4

Averaged over the full 30-day recall period.

5

Center for Epidemiologic Studies – Depression Scale

6

Coded each day as 0 = no drinking, 1 = 1–4 drinks for men/1–3 drinks for women, 2 = 5–11 drinks for men/4–9 drinks for women, and 3 = 12+ drinks for men, 10+ drinks for women.

Figure 1.

Figure 1

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Odds ratios estimated from GEE models for engaging in any sexual intercourse and unprotected intercourse (UI) with any partner type on a given day by daily alcohol use category (with no alcohol use as the reference category)

3.2.2. Unprotected vaginal or anal intercourse (UI)

In Model 1, both the average number of drinks per drinking day and having only steady partners were positively associated with the odds of having UI regardless of partner type, and these relationships remained after accounting for day-level variables in Models 2 and 3 (Table 3, column 2). In Model 2, the quadratic term for alcohol use level on a given day was positively associated with UI. Plotting the odds ratios of each drinking category against no drinking suggested that this relationship appeared to be an inverted “U,” with odds of engaging in UI increasing in the heavy drinking category (men: 5–11 drinks, women: 4–9 drinks, p = .014), but the odds in the lighter and very heavy drinking categories not differing from no drinking (see Figure 1). This relationship did not change after entering terms for marijuana and other drug use in Model 3 and neither of these terms were significant.

3.2.3. UI with a casual partner

In Model 1, only female gender was positively associated with the odds of having UI with a casual partner among those reporting sex with casual partners (Table 3, column 3). This relationship remained in the final model. Neither linear nor quadratic terms for alcohol use level were significant in Model 2. In addition, none of the day-level drug use variables entered in Model 3 were significant. As such, in the full model, only female gender was significantly related to increases in the odds of UI with a casual partner.

4. Discussion

This study is among the first to examine day-level relationships between alcohol use and sexual risk behaviors among heavy drinking, heterosexual emergency department patients. It is unique in its exploration of these associations in a more diverse sample with heavier drinking patterns than past studies. Using TLFB data, we examined whether alcohol use level on a given day was associated with engagement in sex, the use of protection during sex, and the type of partner (“casual” vs. “steady”) involved in UI. Results partially supported our hypotheses. Alcohol use level appeared to increase the odds of engaging in any vaginal or anal sex on a given day, and drinking heavily, but not very heavily, was associated with an increased odds of engaging in UI with any partner type. However, contrary to expectations, alcohol use on a given day was not associated with an increased odds of engaging in UI specifically with casual partners among those reporting casual sex.

Overall, these results are consistent with past experimental studies suggesting that moderate doses of alcohol (BAC≈0.08) are generally associated with increased desire to have sex (George et al., 2009) and intentions to have unprotected sex (Rehm et al., 2012). However, our findings add nuance to these results, showing that (1) increases in UI when drinking heavily may be driven by less condom use with steady partners, and (2) increased odds of UI may be increased uniquely at heavy, but not moderate or very heavy drinking levels.

The finding that alcohol use level on a given day is associated with increases in UI specifically with steady partners is consistent with one prior daily recall study (Scott-Sheldon, Carey, & Carey, 2010a), but inconsistent with many others showing that alcohol use was associated with increased unprotected sex specifically with casual partners (Brown and Vanable, 2007; Kiene et al., 2009; LaBrie et al., 2005). All of these studies focused on college students, however, so these inconsistent results could suggest important differences across samples. For example, college students may be exposed to different social norms around alcohol use and “hooking up” than older adults (Garcia et al., 2012), leading to more frequent casual sex when drinking.

Although unprotected sex with casual partners may perhaps pose the highest risk for HIV/STI transmission, our finding that drinking heavily could increase odds for UI primarily with steady partners is nevertheless important, and may still be an important risk pathway. In this study, reporting sex with a “steady” partner did not necessarily guarantee that sex occurred exclusively with that partner or that efforts to reduce risk had been employed (e.g., communicating about HIV/STI status, having sex concurrently with other partners) . As such, in this study, any UI may represent an important outcome that conveys risk, despite its occurring with a steady partner.

The finding that the increased risk for UI is specific to heavy levels of drinking on a given day, but not very heavy levels (12+ drinks for men, 10+ drinks for women), is surprising. One possible interpretation is that alcohol’s effects on protective decision-making are unique at this level (5–11 drinks for men, 4–9 for women) compared with lower and higher levels of drinking. That is, while alcohol may universally produce higher intentions for engaging in any sexual activity (Rehm et al., 2012), drinking amounts consistent with the lowest drinking category on a given day may not affect judgment and decision-making enough to impact condom use decisions (e.g., Norris et al., 2009). In contrast, drinking very heavily could produce increasingly sedating effects that lead to comparatively conservative decision-making (Wray et al., June, 2013). However, in our study, both drinking and sexual activity were assessed at the day level, so the specific blood alcohol levels and alcohol effects at the time of sex cannot be determined and these interpretations are speculative. Future research using more refined assessment techniques is needed to evaluate this hypothesis. Nevertheless, our results demonstrate that heavy levels of alcohol use on a given day could increase the odds of UI, highlighting the utility of interventions addressing heavy drinking for reducing high-risk sex.

It is important to note that, in general, these results diverge from research conducted with men who have sex with men (MSM), which shows strong support for alcohol’s role in increasing HIV/STI transmission (Sander et al., 2013; Vosburgh et al., 2012). Specifically, studies suggest that very high levels of alcohol use on a given day are associated with increases in unprotected anal intercourse with serodiscordant partners (Kahler et al., 2014; Vosburgh et al., 2012), supporting the need to explore new ways of addressing heavy drinking among MSM to reduce risk for HIV/STIs.

Unsurprisingly, our findings suggest that reporting sex with only steady partners was positively associated with the odds of both having sex and having unprotected sex on a given day, likely reflecting more frequent sex with steady partners and potential reliance on methods of contraception other than condoms. However, several other findings were surprising. First, marijuana use was associated with higher odds of any sex on that day, but neither the day-level or overall use of other drugs (cocaine, heroin, methamphetamine, etc.) were associated with risk outcomes. These results are inconsistent with some global studies suggesting that the use of particular illicit drugs is associated with increased sexual risk (Bogart et al., 2005; Zule et al., 2007). However, the TLFB used in this study did not differentiate between the different types of other drugs used, and it is likely that specific types of drugs, like cocaine and methamphetamine, are associated with risk, given their potential to increase sexual arousal and stamina (Zule et al., 2007), whereas others (e.g., heroin) impede sexual activity (Ross and Williams, 2001; Semaan et al., 2007). Our results may also be due to the relatively low levels of drug use in this sample (only 3.6% of all days were other drug use days).

Among those who had sex with casual partners, female gender was associated with a 1.84 times higher odds of engaging in UI with a casual partner. Indeed, 60% of all unprotected sex events with casual partners occurred among women. Although high rates of lifetime casual sexual partnerships among heterosexual men has produced the assumption that men are at increased risk for HIV/STI acquisition (and subsequent transmission to female partners; see Higgins et al., 2010; Vitellone, 2000), our results suggest that female heavy drinkers who have casual partners could be important targets for intervention. This finding is important because of the higher biological vulnerability to STI and HIV transmission through heterosexual contact among women (Bolan et al., 1999; Cohen, 1998; Moench et al., 2001; Wasserheit, 1992). It should be noted that these results are not explained by higher levels of transactional sex; several participants (5.4%) reported having 15 or more unprotected sex events with casual partners over the 30 days, and of these, 67% (N = 12) were women, but only 17% of these (N = 2) reported engaging in transactional sex in their lifetimes. As such, our results support the continued need to target women in sex risk reduction interventions.

Several limitations should be noted. First, alcohol use level was assessed across the entire day, so the temporal sequence of drinking and sex cannot be definitively established, nor can participants’ intoxication level at the time sex occurred, limiting causal inferences based on these data. Our assessment also focused on the 30 days prior to a hospital visit, so it provided a limited window into patients’ broader behavioral patterns. Finally, as our sample was comprised of heavy drinking adults who reported at least some sexual risk in the past 3 months and volunteered to participate in a behavioral intervention study, this sample may differ in important ways from other samples of ED patients, limiting generalizability.

In summary, this study explored the daily co-occurrence of alcohol use and sexual risk behavior among heavy drinking emergency department patients using TLFB. Alcohol use on a given day was associated with an increased odds of engaging in any sexual intercourse, and these odds incrementally increased with higher levels of drinking. However, only heavy drinking (but not very heavy drinking) was associated with an increased odds of engaging in UI with either steady or casual partners. Alcohol use on a given day was not associated with having UI with a casual partner, suggesting that the increase in UI observed on heavy drinking days is specific to steady partners. These findings suggest that alcohol may play an important role in increasing risk for HIV/STIs, but that it may not universally result in unprotected sex with casual partners, a behavior posing perhaps the highest risk for HIV/STI transmission.

Acknowledgments

This work was supported by grants R01AA009892, T32AA007459, and L30 AA023336.

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