Abstract
Background and Objectives:
Previous findings on the association between hazardous drinking and HIV-risk behavior have been equivocal, varying by population and individual difference factors. This study examined associations between hazardous drinking, impulsivity, and HIV-risk behaviors among HIV-positive Russian patients with a history of injection drug use (IDU), not on antiretroviral therapy.
Methods:
Negative binomial regression analyses of data from a randomized controlled trial were performed (N = 241). Main independent variables were the Alcohol Use Disorders Identification Test and the Barratt Impulsiveness Scale. Outcomes were number of condomless sexual episodes (CSE; primary), number of sexual partners, and needle-sharing frequency (secondary).
Results:
Hazardous drinking was positively associated with the frequency of CSE (adjusted incidence rate ratio [aIRR] = 2.16, 95% confidence interval [CI], 1.98–2.36). Moderate (aIRR = 0.51, 95% CI, 0.46–0.56) and high (aIRR = 0.66, 95% CI, 0.60–0.73) impulsivity were associated with fewer CSE compared with low impulsivity. Hazardous drinking (aIRR = 0.64, 95% CI, 0.52–0.79) and impulsivity (aIRR = 0.95, 95% CI, 0.94–0.96) were both associated with fewer sexual partners. Hazardous drinking and impulsivity were each associated with increased needle sharing. The association between hazardous drinking and number of needle-shares was strongest at higher impulsivity levels.
Conclusion and Scientific significance:
Hazardous drinking may be a risk factor for CSE among HIV-positive Russian patients and may influence needle sharing. Findings contribute to our understanding of the interactive associations between hazardous drinking and impulsivity with sexual risk behaviors and needle sharing among HIV-positive Russian patients with a history of IDU.
INTRODUCTION
While there have been many advances in the prevention and treatment of HIV in the last decade, worldwide incidence rates are still at epidemic proportions with 1.7 million new infections recorded in 2018.1 Specification of factors that contribute to HIV-risk behavior among different populations remains a critical part of developing more efficacious prevention intervention approaches. Hazardous drinking, alcohol consumption patterns that put one at risk for adverse health consequences, maybe particularly important in this regard. The rate of hazardous alcohol consumption among people living with HIV (PLWH) is nearly double that of the general population.2 A number of studies have shown that hazardous drinking is linked with higher rates of sexual risk behavior (eg, condomless sex)3 and a higher likelihood of HIV transmission.4 However, meta-analyses and systematic reviews have raised questions about the magnitude of these effects across populations at heightened risk for HIV,5–7 including the type of hazardous drinking patterns that may represent a risk.8 Further, studies of event-level associations between alcohol and risky sexual behavior have produced mixed results when accounting for personality variables, suggesting that the link between hazardous drinking and HIV-risk behaviors may depend, in part, on such individual factors.9,10 Indeed, a recent systematic review showed evidence that the association between personality-risk variables and risky sexual behavior was often an indirect effect through alcohol and drug use across a variety of HIV-positive samples.11
Among the variety of individual personality factors that have been studied, previous research has suggested that impulsivity may be of particular significance.11,12 The construct of impulsivity refers to a predisposition toward unplanned reactions to environmental or internal stimuli without concern for the undesirable consequences resulting from these reactions.13 Researchers have operationalized impulsivity both as a general construct14,15 and as a multicomponent construct containing specific factors such as sensation seeking (ie, the tendency to seek out novel, exciting experiences), negative urgency (ie, the tendency to behave rashly in response to strong negative emotions), and positive urgency (ie, the tendency to behave rashly in response to strong positive emotions).12,16 A number of studies have shown that higher levels of impulsivity may be associated with more sexual risk behavior.12 Although sexual impulsivity has been associated with more frequent episodes of condomless sex, studies among HIV-positive populations have suggested that the association between general impulsivity and sexual risk may vary based on other risk factors such as alcohol and drug use,17 what sexual risk outcome is examined,18 and the way that it is measured.11 Hazardous alcohol use and impulsivity have also been associated with other indices of HIV-risk, such as needle sharing. A previous work has shown positive associations between hazardous drinking and needle sharing among PLWH who inject drugs.19–21 Similarly, PLWH who inject drugs score higher on measures of impulsivity.22 Taken together, these findings suggest that the associations between hazardous alcohol and/or drug use and impulsivity on the one hand and HIV-risk behavior on the other, may depend on methodological features such as the type of risk behaviors examined, measures utilized, and populations selected.22–24
The current study examined the association between hazardous drinking, impulsivity, and HIV-related risk behavior among Russian PLWH with a history of injection drug use (IDU) receiving addiction treatment and not on antiretroviral therapy at enrollment. It was hypothesized that higher levels of hazardous drinking and impulsivity would be associated with two indices of sexual risk-taking: frequency of condomless sexual episodes and number of sexual partners. In secondary analyses, it was hypothesized that the association between hazardous drinking and these indices of sexual risk-taking would be moderated by levels of impulsivity such that those with high levels of impulsivity would show the strongest evidence of an association between hazardous drinking and sexual risk behavior. The secondary aim of the study was to examine the associations between hazardous drinking and impulsivity on needle sharing for IDU. Given the high rates of IDU within this sample, the associations between hazardous drinking, impulsivity, and the risk behavior of needle sharing were examined among the subset of those who reported current IDU.
MATERIALS AND METHODS
Participants
Data for this secondary analysis comes from the Linking Infectious and Narcology Care (LINC) study: a randomized controlled trial (RCT) of a behavioral and structural intervention designed to support and motivate initiation and retention in HIV-related medical care among Russian PLWH with a history of IDU. Main eligibility criteria for the RCT included (a) age 18 to 70 years, (b) diagnosis of HIV, (c) undergoing addiction treatment at a narcology hospital, and (d) history of IDU, which was defined by an affirmative response to the question, “In your lifetime, have you ever injected drugs?” (for study description and a full list of inclusion and exclusion criteria see Gnatienko et al25). Additional eligibility criteria for the current analyses included having a 6-month follow-up data on hazardous drinking, impulsivity, and sexual risk outcomes (n = 241).
Main Independent Variables
There were two main independent variables in this study, both measured during a 6-month follow-up study visit: hazardous alcohol use and impulsivity. Hazardous alcohol use was assessed using the Alcohol Use Disorders Identification Test (AUDIT), a validated brief 10-item self-report measure commonly used among US and international populations, including PLWH.26 This measure has demonstrated good internal validity and proficiency for identification of harmful alcohol consumption, alcohol abuse, and dependency.27 An AUDIT total score of equal or greater than 8 was used as the threshold for hazardous drinking.
Impulsivity was measured with the 30-item Barratt Impulsiveness Scale (BIS-11).28 The BIS-11 is the most commonly administered self-report measure of impulsivity in both research and clinical settings, used in a wide range of clinical samples, with a considerable focus on substance use populations, and has demonstrated good internal validity and reliability.29 Respondents endorsed items (ie, “I do things without thinking”) using a 4-point scale (ie, “rarely/never” to “almost always/always”). BIS-11 total scores were used in the main analyses.
Outcomes
The primary outcome of this study was number of condomless sexual episodes in the past 90 days assessed using questions adapted from the Women’s Health Coop Baseline Questionnaire30 administered by a research assistant. Participants were asked, “How many times have you had vaginal or anal sex in the past ninety-days, and of those times, how many times was a condom used?” Secondary outcomes included the number of sexual partners in the past 6 months and, among the sample subset reporting current IDU (defined as any use in the past 30 days), number of needle-shares in the past 30 days. Self-administered questions to measure number of sexual partners were developed for this study. Participants were asked, “How many female or male individuals have you had sex within the past six-months?” Research assistant-administered questions modified from the Risk Behavior Survey (RBS)31 were used to assess needle sharing in the past 30 days, a questionnaire that has previously demonstrated reliability and validity.32 Participants were asked, “In the past thirty-days, how many TOTAL different people have you shared works (a syringe or needle)/a cooker (cap, water, filter)/mix?”
Covariates
Age, gender, marital status, CD4 levels below 350, recent involvement in sex trade, cannabis use, and other drug use were selected as covariates for analyses due to their potential as confounding variables influencing the association between hazardous alcohol use, impulsivity, and study outcomes. Because all study participants were enrolled in an RCT, randomization condition was included as an additional covariate in confirmatory adjusted models for all analyses.
Procedures
With the exception of gender and marital status, all data for this study were collected at a 6-month follow-up as part of the LINC trial. In this RCT, participants were randomized to the LINC intervention condition or to a control condition receiving the standard level of care in treatment.25 Study enrollment and procedures were approved by the Institutional Review Board of Boston University Medical Campus and First St. Petersburg Pavlov State Medical University.
Data Analytic Strategy
Descriptive statistics were generated to characterize the overall study sample. Spearman’s correlation coefficients were calculated for the independent variables and covariates, and no pair of variables included in the regression models had a correlation greater than 0.40. The primary outcome, number of condomless sexual episodes, and other count outcomes (ie, number of sexual partners and number of needle-shares) were analyzed using negative binomial regression models due to overdispersion in the data (ie, the variance exceeds the mean) adjusting for potential confounders. Dichotomous outcomes (eg, any condomless sexual episodes) were analyzed similarly using multiple logistic regression. Hazardous drinking was modeled as a dichotomous variable for all analyses. BIS-11 total score was modeled as a three-level categorical variable defined based on tertiles for the primary and some secondary analyses, as the linearity assumption did not appear to hold. However, for analyses in which secondary outcomes exhibited a linear association with BIS-11 total score (eg, the association between impulsivity and number of sexual partners), impulsivity was modeled as continuous to improve power. To assess potential effect modification, we also tested interactions between BIS-11 total score and hazardous drinking in secondary analysis models. If the interaction was statistically significant, subsequent analyses were conducted stratified by impulsivity level in order to describe how the association between hazardous drinking and the outcomes of interest differed by level of impulsivity.
A secondary aim of the study was to examine the effect of hazardous drinking and impulsivity on needle sharing. The subsample of participants who reported current IDU was analyzed using negative binomial regression models, as described above. The main effects were analyzed to examine the influence of hazardous drinking and BIS-11 total score on the number of needle-shares among this subsample. An interaction model was run for BIS-11 total score and hazardous drinking to assess for moderation effects. Two-tailed tests and an α level of .05 were used for all hypotheses tested. Analyses were performed using SAS version 9.3 (SAS Institute, Inc., NC).
RESULTS
Descriptive Statistics
Participant demographics stratified by BIS-11 total score are presented in Table 1. The mean age of the study sample was 34.3 years (SD = 4.8), 63 (26%) participants were women, 142 (59%) were hazardous drinkers, and the mean BIS-11 total score was 71.8 (SD = 10.8). The mean number of condomless sexual episodes in the past 90 days among the sample was 12.6 (SD = 31.7), with 104 (43%) participants endorsing at least one condomless sexual episode during that period; the mean number of sexual partners in the past 6 months was 1.9 (SD = 9.7), with 65 (27%) participants reporting two or more sexual partners within that time frame. Over half of the participants (n = 127, 53%) indicated current IDU. Among the subsample with current IDU, a mean of 9.3 (SD = 15.3) needle-shares was reported in the past 30 days.
TABLE 1.
Descriptive statistics stratified by impulsivity
| Question | Response | Overall | Impulsivity (47–66) | Impulsivity (67–74) | Impulsivity (75–109) | P value |
|---|---|---|---|---|---|---|
| Impulsivity score—Categorical | N | 241 | 73 | 81 | 87 | <.0001* |
| Mean (SD) | 71.8 (10.8) | 59.9 (5.1) | 70.7 (2.4) | 82.8 (7.4) | ||
| Min, 25th, Median, 75th, Max | 47, 64, 71, 79, 109 | 47, 57, 61, 64, 66 | 67, 68, 71, 73, 74 | 75, 78, 80, 85, 109 | ||
| Hazardous alcohol use (AUDIT) | No | 99 (41.1%) | 39 (53.4%) | 35 (43.2%) | 25 (28.7%) | .0060* |
| Yes | 142 (58.9%) | 34 (46.6%) | 46 (56.8%) | 62 (71.3%) | ||
| Unprotected sexual episodes, past 90 days | N | 241 | 73 | 81 | 87 | .3834 |
| Mean (SD) | 12.6 (31.7) | 16.3 (47.4) | 9.2 (19.3) | 12.7 (23.6) | ||
| Min, 25th, Median, 75th, Max | 0, 0, 0, 10, 360 | 0, 0, 0, 10, 360 | 0, 0, 0, 6, 90 | 0, 0, 0, 12, 100 | ||
| Any unprotected sexual episodes, past 90 days | No | 137 (56.8%) | 44 (60.3%) | 49 (60.5%) | 44 (50.6%) | .3356 |
| Yes | 104 (43.2%) | 29 (39.7%) | 32 (39.5%) | 43 (49.4%) | ||
| Number of partners, past 6 months | N | 241 | 73 | 81 | 87 | .3269 |
| Mean (SD) | 1.9 (9.7) | 3.3 (17.4) | 1.5 (1.9) | 1.1 (1.1) | ||
| Min, 25th, Median, 75th, Max | 0, 1, 1, 2, 150 | 0, 1, 1, 2, 150 | 0, 1, 1, 2, 12 | 0, 0, 1, 1, 5 | ||
| Number of partners, past 6 months | 0–1 | 176 (73.0%) | 49 (67.1%) | 59 (72.8%) | 68 (78.2%) | .2927 |
| 2+ | 65 (27.0%) | 24 (32.9%) | 22 (27.2%) | 19 (21.8%) | ||
| Current IDU | No | 114 (47.3%) | 42 (57.5%) | 40 (49.4%) | 32 (36.8%) | .0292 |
| Yes | 127 (52.7%) | 31 (42.5%) | 41 (50.6%) | 55 (63.2%) | ||
| Number of needle-shares, past 30 days | N | 127 | 31 | 41 | 55 | .3298 |
| Mean (SD) | 9.3 (15.3) | 6.8 (15.7) | 8.2 (13.0) | 11.6 (16.5) | ||
| Min, 25th, Median, 75th, Max | 0, 0, 1, 14, 60 | 0, 0, 0, 4, 60 | 0, 0, 1, 10, 60 | 0, 0, 4, 18, 60 | ||
| Age, y | N | 241 | 73 | 81 | 87 | .0010* |
| Mean (SD) | 34.3 (4.8) | 35.6 (4.4) | 34.8 (5.3) | 32.8 (4.4) | ||
| Min, 25th, Median, 75th, Max | 24.1, 30.9, 34.2, 37.4, 48.9 | 24.8, 32.7, 35.8, 38.4, 47.4 | 24.4, 30.9, 33.9, 38.0, 48.9 | 24.1, 30.0, 32.9, 35.3, 44.4 | ||
| Gender | Male | 178 (73.9%) | 60 (82.2%) | 66 (81.5%) | 52 (59.8%) | .0009* |
| Female | 63 (26.1%) | 13 (17.8%) | 15 (18.5%) | 35 (40.2%) | ||
| Married or partnered | No | 158 (65.6%) | 55 (75.3%) | 50 (61.7%) | 53 (60.9%) | .1080 |
| Yes | 83 (34.4%) | 18 (24.7%) | 31 (38.3%) | 34 (39.1%) | ||
| CD4 cell count, baseline | 0–350 | 125 (54.6%) | 37 (50.7%) | 41 (53.9%) | 47 (58.8%) | .6004 |
| >350 | 104 (45.4%) | 36 (49.3%) | 35 (46.1%) | 33 (41.3%) | ||
| Received money/drugs for sex, past 6 months | No | 231 (95.9%) | 71 (97.3%) | 81 (100.0%) | 79 (90.8%) | .0089* |
| Yes | 10 (4.1%) | 2 (2.7%) | 0 (0.0%) | 8 (9.2%) | ||
| Used cannabis, past 6 months | No | 180 (74.7%) | 60 (82.2%) | 59 (72.8%) | 61 (70.1%) | .1937 |
| Yes | 61 (25.3%) | 13 (17.8%) | 22 (27.2%) | 26 (29.9%) | ||
| Used other drugs, past 6 months | No | 73 (30.3%) | 30 (41.1%) | 27 (33.3%) | 16 (18.4%) | .0060* |
| Yes | 168 (69.7%) | 43 (58.9%) | 54 (66.7%) | 71 (81.6%) |
Bolded P-values represent significance <.05,
P < .01.
IDU = injection drug use.
Effects of Hazardous Drinking and Impulsivity on Sexual Risk Behaviors
The primary analysis examined the main effects of hazardous drinking and impulsivity on the frequency of condomless sexual episodes in the last 90 days. Regression results revealed a statistically significant positive association between hazardous drinking and number of condomless sexual episodes (adjusted incidence rate ratio [aIRR] = 2.16, 95% confidence interval [CI], 1.98–2.36, P < .001).*,† In contrast, BIS-11 total score was negatively associated with the number of condomless sexual episodes (global P < .001); specifically, a higher BIS-11 total score was associated with fewer condomless sexual episodes. The medium and high tertiles of BIS-11 total score were significantly different from the low BIS-11 total score tertile in number of condomless sexual episodes (medium vs low: aIRR = 0.51; 95% CI, 0.46–0.56, P < .001, high vs low: aIRR = 0.66, 95% CI, 0.60–0.73, P < .001).‡ Results of the fully adjusted main effects model for this outcome are presented in Table 2.§
TABLE 2.
Association between alcohol, impulsivity, and number of condomless sexual episodes
| Primary outcome: Number of condomless sexual episodes | Unadjusted model IRR (95% CI) | Primary adjusted model aIRR (95% CI) |
|---|---|---|
| Overall sample, n = 241 | n = 241 | n = 229 |
| Hazardous drinking | 1.62 (1.50–1.75)* | 2.16 (1.98–2.36)* |
| Impulsivity 47–66 | Reference | Reference |
| Impulsivity 67–74 | 0.54 (0.49–0.59)* | 0.51 (0.46–0.56)* |
| Impulsivity 75–109 | 0.70 (0.64–0.76)* | 0.66 (0.60–0.73)* |
| Gender, female | 1.08 (0.98–1.18) | |
| Married or partnered, yes | 2.51 (2.32–2.71)* | |
| CD4 cell count, 0–350 | 0.81 (0.75–0.87)* | |
| Received money/drugs for sex, past 6 months, yes | 0.61 (0.45–0.81)* | |
| Used cannabis, past 6 months, yes | 1.00 (0.92–1.10) | |
| Used other drugs, past 6 months, yes | 0.40 (0.37–0.44)* | |
| Age | 0.99 (0.98–1.00)* |
This primary regression model adjusts for gender, marital status, CD4 count <350, receipt of recent sex trade, cannabis use, and other drug use. Number of condomless sexual episodes was modeled using negative binomial regression. Hazardous drinking refers to hazardous drinking as measured an AUDIT score of 8 or more. Impulsivity was modeled as a three-level category. Impulsivity 47–66 was used as the reference group for the analysis. Impulsivity 67–74 refers to the contrast between the middle tertile of the categorical impulsivity variable and the lowest tertile as the reference group. Impulsivity 75–109 refers to the contrast between the highest tertile of the categorical impulsivity variable and the lowest tertile as the reference group. Covariate reference groups: gender = female; married or partnered = yes; CD4 cell count = 0–350; received money/drugs for sex, past 6 months = yes; used cannabis, past 6 months = yes; used other drugs, past 6 months = yes.
aIRR = adjusted incidence rate ratio; CI = confidence interval; IRR = incidence rate ratio.
P < .01.
A secondary analysis was conducted to examine whether there was an interaction between impulsivity and hazardous drinking on the number of condomless sexual episodes in the past 90 days. Following evidence of a significant interaction (global P < .001), stratification of results by BIS-11 total score tertile (eg, low, medium, and high) were conducted. These analyses showed a significant positive association between hazardous drinking and number of condomless sexual episodes at all levels of BIS-11 total score (low tertile: aIRR = 3.62, 95% CI, 3.19–4.11, P < .001; medium tertile: aIRR = 1.24, 95% CI, 1.03–1.49, P = .025; high tertile: aIRR = 1.48, 95% CI, 1.25–1.75, P < .001). Unexpectedly, the strongest association between hazardous drinking and number of condomless sexual episodes was found among those with the lowest BIS-11 total scores.
Analysis of the association between hazardous drinking, BIS-11 total score (modeled as a continuous variable), and the secondary outcome of number of sexual partners in the past 6 months showed that hazardous drinking was associated with fewer sexual partners (aIRR = 0.64, 95% CI, 0.52–0.79, P < .001) as was BIS-11 total score (aIRR = 0.95 per 1-point increase in BIS-11 total score, 95% CI, 0.94–0.96, P < .001), indicating that those without hazardous drinking and with lower BIS-11 total scores both reported a greater number of sexual partners. However, this effect was not significant for either hazardous drinking (aIRR = 1.19, 95% CI, 0.88–1.59, P = ns) or impulsivity (aIRR = 0.99, 95% CI, 0.99–1.00, P = ns) when sex workers were excluded from this analysis. The interaction between hazardous drinking and BIS-11 total score was not significant (global P = .16). Results of the fully adjusted model of main effects for this outcome are shown in Table 3.
TABLE 3.
Association between alcohol, impulsivity, and number of sexual partners
| Number of sexual partners | Unadjusted model IRR (95% CI) | Primary adjusted model aIRR (95% CI) |
|---|---|---|
| Overall sample, n = 241 | n = 241 | n = 229 |
| Hazardous drinking | 0.54 (0.45–0.65)* | 0.64 (0.52–0.79)* |
| Impulsivity—continuous | 0.97 (0.96–0.98)* | 0.95 (0.94–0.96)* |
| Gender, female | 1.39 (1.11–1.74)* | |
| Married or partnered, yes | 0.90 (0.71–1.14) | |
| CD4 cell count, 0–350 | 1.05 (0.84–1.31) | |
| Received money/drugs for sex, past 6 months, yes | 11.73 (9.00–15.29)* | |
| Used cannabis, past 6 months, yes | 0.56 (0.43–0.72)* | |
| Used other drugs, past 6 months, yes | 1.87 (1.45–2.41)* | |
| Age | 1.01 (0.99–1.04) |
This primary regression model adjusts for gender, marital status, CD4 count <350, receipt of recent sex trade, cannabis use, and other drug use. A number of sexual partners were modeled using negative binomial regression. Hazardous drinking refers to hazardous drinking as measured an AUDIT score of 8 or more. Impulsivity was modeled as a continuous variable. Covariate reference groups: gender = female; married or partnered = yes; CD4 cell count = 0–350; received money/drugs for sex, past 6 months = yes; used cannabis, past 6 months = yes; used other drugs, past 6 months = yes.
aIRR = adjusted incidence rate ratio; CI = confidence interval; IRR = incidence rate ratio.
P < .01.
Hazardous Drinking, Impulsivity, and Needle Sharing Among Those Who Currently Inject Drugs
As a secondary aim, the main and interaction effects of hazardous drinking and impulsivity on the HIV-risk behavior of needle sharing in the past 30 days were examined among the study subsample reporting current IDU. Regression analyses indicated a statistically significant positive association between both hazardous drinking and BIS total score and needle-sharing frequency (hazardous drinking: aIRR = 1.39, 95% CI, 1.19–1.61, P < .001; impulsivity: aIRR = 1.02 per one-point increase in BIS-11 total score, 95% CI, 1.01–1.02, P < .001). A greater number of needle-shares occurred among those with higher rates of hazardous drinking as well as among those with higher BIS-11 total scores.
Analysis of interaction effects demonstrated a statistically significant interaction between hazardous drinking and BIS-11 total score (aIRR = 1.03, 95% CI, 1.01–1.05, P < .001). Among those in the lowest BIS-11 total score tertile, hazardous drinking was associated with a lower number of needle-shares (aIRR = 0.34, 95% CI, 0.23–0.51, P < .001), while results for moderate and high BIS-11 total score showed significant positive associations between hazardous drinking and needle sharing (medium tertile: aIRR = 1.43, 95% CI, 1.10–1.85, P < .01; high tertile: aIRR = 2.62, 95% CI, 1.99–3.45, P < .001). Results from the fully adjusted main effects model are presented in Table 4.
TABLE 4.
Association between alcohol, impulsivity, and number of needle-shares among sample reporting current IDU
| Number of needle-shares | Unadjusted model IRR (95% CI) | Primary adjusted model aIRR (95% CI) |
|---|---|---|
| Overall sample, n = 127 | n = 127 | n = 119 |
| Hazardous drinking | 1.55 (1.35–1.79)* | 1.39 (1.19–1.61)* |
| Impulsivity—continuous | 1.02 (1.02–1.03)* | 1.02 (1.01–1.02)* |
| Gender, female | 0.85 (0.74–0.99)+ | |
| Married or partnered, yes | 1.03 (0.90–1.18) | |
| CD4 cell count, 0–350 | 1.27 (1.11–1.46)* | |
| Received money/drugs for sex, past 6 months, yes | 1.15 (0.89–1.48) | |
| Used cannabis, past 6 months, yes | 0.90 (0.79–1.03) | |
| Used other drugs, past 6 months, yes | 0.30 (0.20–0.45)* | |
| Age | 0.96 (0.95–0.98)* |
These exploratory regression models adjusted for gender, marital status, CD4 count <350, receipt of recent sex trade, cannabis use, and other drug use. A number of needle-sharing episodes were modeled using negative binomial regression. Hazardous drinking refers to hazardous drinking as measured an AUDIT score of 8 or more. Impulsivity was modeled as a continuous variable for these analyses.
aIRR = adjusted incidence rate ratio; CI = confidence interval; IDU = injection drug use; IRR = incidence rate ratio.
P < .05.
P < .01.
DISCUSSION
Previous research examining the link between alcohol use and risky sexual behaviors has yielded mixed results varying by study population and type of risky sexual behavior measured.3,4,9,33 Even among studies of Russian PLWH, a positive association between indices of heavy drinking and increased sex risk has been observed in some research,19,34 but not in others.35 Research on impulsivity and risky sexual behaviors among HIV-positive populations has been similarly inconclusive.15,17,18,23 The equivocal nature of these findings may be attributable to major differences in study populations (eg, men that have sex with men, current substance users, young adults), recruitment methods, measures of impulsivity, settings (eg, countries with harsh criminalization of drug use, HIV-treatment centers), and the variation of HIV-risk behavior prevalence rates among these groups.
The current study sought to assess the associations between hazardous drinking and impulsivity with HIV-risk behaviors (both sexual and IDU) among a sample of HIV-positive Russians who were in addiction treatment and not yet engaged in HIV care (thus not on antiretroviral therapy) at enrollment. In line with the study hypotheses, these results provide evidence of a positive association between hazardous alcohol use and frequency of condomless sexual episodes in the last 90 days. Results from this study add support to the evidence of a positive direct association between hazardous drinking and increased condomless sexual encounters among Russian HIV-positive hazardous drinkers. Findings from this study replicate and extend results from previous work with a similar study sample showing a positive association between alcohol use and condomless sex,19 further endorsing hazardous alcohol use as a significant predictor of this index of HIV sexual risk behavior. These findings, of course, are also critically relevant to the risk of other sexually transmitted infections, which may represent an increased risk to the health of PLWH.36
In contrast, a number of findings regarding impulsivity were contrary to the study hypotheses. Higher BIS-11 total scores of impulsivity were negatively associated with condomless sexual episodes in the past 90 days, with the highest risk found among the lowest levels of impulsivity. The secondary analysis models of the interaction effects suggested that the strength of the association between hazardous alcohol use and condomless sexual episodes may be weaker among those with higher vs lower impulsivity levels. Analyses of the number of sexual partners also produced unexpected findings. In contrast to previous work that has shown a positive association between alcohol consumption and multiple sexual partners among Russian PLWH,33,37 the results of this study found that hazardous alcohol use, as well as higher impulsivity levels, were negatively associated with number of sexual partners in the past 6 months. The interaction between the BIS-11 total score and hazardous drinking was not significant. Individual differences in gender and sexual orientation as well as contextual factors such as partner type, partner HIV status, and partner use of substances should be further assessed as potential moderators of the association between impulsivity and sexual risk.18
Findings from the secondary analyses of the subsample reporting current IDU provided support for both hazardous alcohol use and impulsivity as significant predictors of the number of needle-shares in the past 30 days, with the strongest association between hazardous drinking and needle sharing frequency found among those with the highest level of impulsivity. These findings are consistent with previous work that has shown positive associations between higher-risk drinking and both needle sharing and needle-sharing frequency among people who inject drugs, HIV-positive people who inject drugs, and Russian HIV-positive people who inject drugs specifically.19–21 Previous work has suggested that HIV-positive people who inject drugs score higher on measures of impulsivity and specific aspects of impulsivity related to risk-taking behaviors (ie, disinhibition, sensation seeking).22
Given that both risky sexual behavior and IDU are the two primary sources of HIV transmission in Russia,38 the identification of both behavioral and personality factors associated with these high-risk behaviors is critical to decrease rates of HIV infection. The findings regarding needle sharing suggest that among Russian HIV-positive people who inject drugs, high levels of impulsivity may be a promising marker for those at the highest risk for HIV transmission and/or those requiring individual treatment plans. Strategies aimed at decreasing alcohol use and addressing impulsivity appear to be important to include in HIV-risk reduction approaches for this population. The selection of these strategies will be improved with a better understanding of the mechanisms through which alcohol and impulsivity may be linked to risk behaviors. Hazardous drinking may lead to increased sexual risk behavior through a variety of motivational and cognitive mechanisms including higher arousal, diminished capacity to utilize relevant coping skills, and state changes in the ability to inhibit responses.39,40
Future research on the impact of impulsivity on the alcohol-sex risk relationship among Russian PLWH should include an assessment of specific aspects of impulsivity to identify specific construct domains that may be most relevant for this population (eg, rash impulsiveness, sensation seeking) that may be assessed with multidimensional measures such as the UPPS-P (Urgency, Premeditation [lack of], Perseverance [lack of], Sensation Seeking, Positive Urgency, Impulsive Behavior Scale).41 There should also be consideration of alternative indices of sexual risk-taking (eg, taking into account the number of partners within the number of episodes of condomless intercourse reported) to better assess the highest risk-taking behaviors. Moreover, given the apparent differences across populations, future work should consider distinguishing different subpopulations of Russian PLWH (eg, type of drug use, MSM) in analyses.
This study is not without limitations. First, the study was a cross-sectional analysis of individuals participating in an RCT. Second, total scores from the Barratt Impulsiveness Scale were used to assess impulsivity in this sample, rather than a more fine-grained assessment of subcomponents of impulsivity that have been identified within the construct,42 though it must be noted that recent work has raised questions about the utility of a multidimensional solution of the Barrett Impulsiveness Scale.43,44 The study used the AUDIT to measure hazardous drinking. Although this has been well-established as a measure for use in multiple countries by the World Health Organization (WHO),45 it is a screening measure and not designed to provide fine-grained analyses of patterns of alcohol use that may be linked to HIV-risk. Despite these limitations, this study provides one of the few studies to examine the association between hazardous drinking, impulsivity, and HIV-related risk behavior, specifically among Russian PLWH in addiction treatment.
CONCLUSIONS
Findings from this study support hazardous drinking and impulsivity as risk factors for distinct HIV-risk behaviors. Results showed that hazardous drinking was associated with a higher frequency of condomless sexual episodes, but not more partners. Both hazardous drinking and impulsivity were independently associated with greater needle-sharing frequency among the sample subset reporting current IDU. Moreover, the association between hazardous drinking and needle sharing was strongest among those highest in impulsivity.
Acknowledgments
This work was supported by Award Number R01DA032082 from the National Institute on Drug Abuse (Bethesda, MD) awarded to PI Jeffrey Samet, MD, MA, MPH, and by the Providence/Boston Center for AIDS Research (grant P30AI042853).
Footnotes
Declaration of Interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper.
Additional analyses were conducted to examine the association between the WHO (2019) designated levels of hazardous/harmful drinking (0–7 [none], 8–15, 16–10, 20+) and frequency of condomless sexual episodes and number of partners. These results showed that higher levels of hazardous drinking as measured by the AUDIT was associated with greater frequency of condomless sexual episodes. The aIRRs with no hazardous drinking as the reference group for number of condomless episodes was as follows: aIRR category 8–15 = 1.46, 95% CI, 1.30–1.63, P < .001; aIRR category 16–19 = 1.97, 95% CI, 1.72–2.26, P < .001; aIRR category 20+= 2.98, 95% CI, 2.71–3.29, P < .001. The aIRRs with no hazardous drinking as the reference group for number of partners was as follows: aIRR category 8–15 = 0.64, 95% CI, 0.49–0.84, P < .01; aIRR category 16–19 = 0.45, 95% CI, 0.27–0.76, P < .01; aIRR category 20+= 0.69, 95% CI, 0.53–0.89, P < .01.
Additional analyses were conducted to examine the association between gender-specific AUDIT scores (7+ for women; 8+ for men) to identify hazardous drinking and frequency of condomless sexual episodes and number of partners. Results were similar to the main analyses for condomless episodes (aIRR = 2.13, 95% CI, 1.952.32, P < .001) and number of partners (aIRR = 0.62, 95% CI, 0.51–0.76, P < .001).
Additional analyses were conducted to examine the association between hazardous drinking and frequency of condomless sexual episodes with number of partners by excluding those who were engaged in sex work (one of whom resulted in a significant outlier). Results were similar to the main analyses for the frequency of condomless sexual episodes (aIRR = 2.16, 95% CI, 1.98–2.37, P < .001) but not for number of partners, which became nonsignificant (aIRR = 1.19, 95% CI, 0.88–1.59, P= ns).
These and all subsequent analyses were repeated using treatment condition from the LINC trial as an additional covariate to confirm results. Results were not meaningfully changed with the addition of this covariate.
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