Abstract
Purpose
To examine health risk behaviors in distressed youth living with HIV (YLH) with problem substance use.
Methods
Assessed distress, antiretroviral (ARV) adherence, and unprotected sex in a racially and geographically diverse sample of 122 YLH.
Results
A total of 87% of distressed YLH reported significantly more past-month ARV nonadherence (odds ratio [OR] = 7.15) and were more likely to have unprotected sex under the influence (OR = 5.14) than non-distressed youth.
Conclusions
Distressed YLH with problem substance youth may benefit from interventions to improve adherence and to decrease sexual risk, especially while under the influence of drugs.
Keywords: substance abuse, unprotected sex, HIV, adherence, youth
Substance use among youth living with HIV (YLH) has been linked with both poor adherence to antiretroviral (ARV) medications and unprotected intercourse, 1,2 and predictors of such behaviors are important to determine in order to decrease the risk of HIV transmission and to improve the quality of the lives of the youth. Emotional distress may be an important influence on these behaviors. Symptoms of distress or depression, common among YLH in general, have been significantly associated with less ARV adherence;1,3 in contrast, emotional distress has not been consistently associated with condom use in YLH.2 However, no published investigations have explored the relationships between distress, antiretroviral adherence and sex risk in YLH who report problem substance use. Furthermore, prior examinations of YLH have not examined more specific conditions of sex risk, such as engaging in unprotected sex while under the influence of alcohol or drugs. The current investigation of a racially and geographically diverse sample of YLH focuses specifically on those with problem substance use to examine differences in sex behaviors and medication adherence in those who report clinically elevated levels of distress relative to those who do not report elevated distress. Due to the deleterious effects of distress, we hypothesize that problem substance users with high levels of distress will report poorer antiretroviral adherence and more unprotected sex, particularly while under the influence of substances, compared to non-distressed peers.
Methods
Participants
Youth living with HIV were aged 16 to 24 and were participants in an investigation of an intervention for health risk behaviors 4 at 5 sites of the Adolescent AIDS Trials Network. Youth selected for the intervention engaged in at least one of three problematic behaviors: substance use (66%), unprotected sex (54%), or nonadherence to antiretroviral treatment (44%).5 Of 375 screened patients, 151 were ineligible, and 19 refused to enroll. Of 205 participants enrolled, 19 did not complete baseline data collection. Present analyses focus on baseline data of youth reporting problem substance use (N = 122).
Procedures
After Institutional Review Board approval, participants were approached during clinic visits and informed consent/assent was obtained. Data were collected by research interviewers using computer-assisted personal interviewing and participants received $30 compensation.
Measures
Problem alcohol and drug use was assessed with the CRAFFT, a 6-item screening instrument for adolescents with 92% sensitivity to identify those who need treatment for alcohol or drug use. 6 Three items assessing lifetime use were reworded to reflect use in the last 3 months. As recommended, a cutoff score of 2 or greater was used to identify problem substance users.
Emotional distress during the past week was measured with the Global Symptom Index (GSI) of the Brief Symptom Inventory7. The Brief Symptom Inventory possesses strong psychometric evidence, has been widely-used in research with HIV-infected and adolescent populations, and permits use of adolescent norm-referenced T-scores. 7–10 Consistent with extant research, as well as manual recommendations, clinically significant levels of distress were indicated in the present investigation by T-scores > 63. 7
Antiretroviral Medication Adherence was determined by items reflecting past three days of use. Participants also reported whether they had taken their medications more or less than 90% of the time in the last month (Naar-King et al., under review).
Unprotected sex in the past 3 months was assessed with the Sexual Risk Behavior Scale.5 Present analyses focus on (1) overall endorsement of unprotected sex acts and (2) reported unprotected sex acts occurring while under the influence of drugs or alcohol.
Data Analysis
Participants were grouped on the basis of self-reported clinical elevations in distress. Hierarchical logistic regression (HLR) models were conducted to examine the associations of clinically significant distress with medication adherence and sex risk behaviors. Demographic variables (age, gender and ethnicity) were entered as the first step in each model, as demographics have previously been associated with distress as well as the outcome variables.
Results
Participants were 16 to 24 years old (M = 20.86, SD = 2.24), primarily African American (81%), and more than half were male (57%). Nearly half (49%) were prescribed antiretroviral medications; adherence analyses focus only on youth prescribed medications (n = 60). Over half (57%) of the sample reported having used alcohol in the past month, 51% reported past-month marijuana use, and 13% reported other illicit drugs.
As shown in Table 1, distressed youth were significantly more likely to report less than 90% adherence with antiretroviral medication in the past 3 days (79% vs. 52%; adjusted odds ratio [AOR] = 3.83; p = .03) and in the past month (87% vs 37%, AOR = 7.15; p = .01).
Table 1.
Associations of clinically elevated levels of distress with medication adherence
| <90% adherence | % nonadherent of nondistressed | % nonadherent of distressed | Adjusted OR | 95% CI | p |
|---|---|---|---|---|---|
| Past 3 days | 51.7% | 79.3% | 3.83 | 1.11–13.19 | .03 |
| Past month | 36.7% | 87.1% | 7.15 | 1.49–34.27 | .01 |
Adjusted OR = Multivariate Logistic Regression (controlling for age, gender, and ethnicity)
Sex risk behaviors are shown in Table 2. Although youth reporting clinically elevated levels of distress did not report higher incidence of unprotected sex (53% vs. 52%), distressed youth were significantly more likely to report unprotected sex while under the influence of drugs or alcohol (43% vs 18%; AOR = 5.14; p = .004).
Table 2.
Associations of clinically elevated levels of distress with sex risk behaviors in the last 3 months
| Risk Behavior | % risky of nondistressed | % risky of distressed | Adjusted OR | 95% CI | p |
|---|---|---|---|---|---|
| Unprotected sex | 51.6% | 52.7% | .99 | .46–2.15 | .93 |
| Unprotected sex while under the influence | 17.6% | 42.9% | 5.14 | 1.71–15.42 | .003 |
Adjusted OR = Multivariate Logistic Regression (controlling for age, gender, and ethnicity)
Discussion
Consistent with our hypotheses, distressed YLH with problem substance use were > three times more likely to report poor antiretroviral medication adherence than their non-distressed peers. This is particularly worrisome since antiretroviral nonadherence is linked with worse health and progression of disease. Moreover, unprotected sex in the context of poor or inconsistent adherence may result in the transmission of resistant strains of the virus, as well as greater likelihood of transmission due to higher viral loads. Interestingly, although about half of both groups had unprotected sex, distressed YLH with problem substance use were significantly less likely than non-distressed youth to use a condom while under the influence of substances. Risky sex while under the influence is particularly concerning as it may be associated with higher-risk sexual activities with serodiscordant partners or poor implementation of safer-sex behaviors such as negotiation and correct condom use.11 This study did not address potential mechanisms linking distress or mood disorders with increased sex risk while under the influence. Differences may exist between distressed and non-distressed youth with problem substance use regarding their motivation for substance use (e.g., self-medication), their motivations for sex (e.g., use of sex to avoid negative affect or rejection by a partner), and the presence of psychiatric comorbidities (e.g., depressive or posttraumatic stress disorders). Given the evidence for increased personal and public health risk associated with distress in YLH with problem substance use, screening of youth for substance use, distress, and psychiatric comorbidities may permit prompt identification and referral for appropriate services.
The present sample of youth willing to enroll in an adherence intervention study may not generalize to the broader population of substance using YLH, particularly those using injection drugs and methamphetamine, However, this study did enroll a large, racially and geographically diverse sample of YLH which adds to the generalizability of the findings. The cross-sectional nature of analyses additionally limits the ability to infer causality, although the associations are clear. YLH with problem substance use are thought to be at particular risk for adverse outcomes and these findings demonstrate a significant association between greater levels of distress and less adherence to ART. Moreover, greater distress is associated with engaging in unprotected sex when under the influence of substances. Further study is required to better understand the causal nature of this association. Clinically, the data support the importance of providing appropriate attention to psychological distress, substance use, medication adherence, and sex risk behaviors among YLH.
Acknowledgments
This work was supported by The Adolescent Trials Network for HIV/AIDS Interventions (ATN) from the National Institutes of Health [U01 HD 040533 and U01 HD 040474] through the National Institute of Child Health and Human Development (B. Kapogiannis, S. Lee)], with supplemental funding from the National Institutes on Drug Abuse (N. Borek) and Mental Health (P. Brouwers, S. Allison). Support was provided by the ATN Coordinating Center (C. Wilson, C. Partlow) at The University of Alabama at Birmingham and the ATN Data and Operations Center at Westat, Inc. (J. Korelitz, J. Davidson, B. Harris). Manuscript preparation support was provided by T32MH 078788 (PI: L.Brown) and the Lifespan/Tufts/Brown Centers for AIDS Research. The following sites participated in this study: Children’s Diagnostic and Treatment Center (A. Puga, MD, E. Leonard, BSN, Z. Eysallenne, RN); Childrens Hospital of Los Angeles (M. Belzer, MD, C. Salata, RN, D. Tucker, RN, MSN); University of Maryland (L. Peralta, MD, L. Flores, MD, E. Collinetti, BA); University of Pennsylvania and the Children’s Hospital of Philadelphia (B. Rudy, MD, M. Tanney, MPH, MSN, CPNP, A. DiBenedetto, BSN); and Wayne State University Horizons Project (K. Wright, D.O., P. Lam, M.A., V. Conners, B.A.).
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