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Objective: College students are among the age-group most affected by sexually transmitted infections, yet few evidence-based interventions have proved effective in increasing college student condom use. The goal of this study was to determine which combination of referent proximity and width of discrepancy between perceived and actual norms within a normative feedback intervention produced the greatest motivation to increase condom use among US college students. Design: A 2 (proximity) × 2 (width of discrepancy) × 2 (gender) randomised-factorial experiment was conducted. Setting: Sexually active college students ( N = 212; 50.5% female; 70.4% White) were recruited via Amazon Mechanical Turk, an online labour market. Method: Participants were randomised, stratified by gender, to one of four sham feedback conditions: proximal referent wide discrepancy, proximal referent narrow discrepancy, distal referent wide discrepancy and distal referent narrow discrepancy. Following delivery of the feedback, participants completed measures assessing their willingness to change their condom use. Results: A three-way factorial analysis of covariance revealed a significant interaction between referent proximity and width of discrepancy ( F = 7.88, p = .005, [Formula: see text]), such that the effect of proximity on willingness to use condoms was greater in the narrow, compared with wide, discrepancy condition. Conclusion: Findings from this study indicate that it may be beneficial to assess students’ perceptions of their peers’ sexual behaviour before selecting the reference group to include within normative feedback. This is the first study to demonstrate that the importance of selecting referents within normative feedback may be dependent on the accuracy of students’ perceptions.

Alcohol use among people living with HIV (PWH) has been increasingly recognized as an important component of HIV care. Transdiagnostic treatments, such as Acceptance and Commitment Therapy (ACT), that target core processes common to multiple mental health and substance-related problems, may be ideal in HIV treatment settings where psychological and behavioral health comorbidities are high. In advance of a randomized clinical trial (RCT), the overall objective of this study was to systematically adapt an ACT-based intervention originally developed for smoking cessation, into an ACT intervention for PWH who drink at hazardous levels. Consistent with the ADAPT-ITT model, the adaptation progressed systematically in several phases, which included structured team meetings, three focus group discussions with PWH (N = 13), and in-depth interviews with HIV providers (N = 10), and development of standardized operating procedures for interventionist training, supervision, and eventual RCT implementation. The procedures described here offer a template for transparent reporting on early phase behavioral RCTs.

Affect has been linked to risky sexual decision-making and may be particularly important for college students. Research has overlooked the role of affective arousal, rather focusing exclusively on ...

Author(s): Hahn, Judith A; Murnane, Pamela M; Vittinghoff, Eric; Muyindike, Winnie R; Emenyonu, Nneka I; Fatch, Robin; Chamie, Gabriel; Haberer, Jessica E; Francis, Joel M; Kapiga, Saidi; Jacobson, Karen; Myers, Bronwyn; Couture, Marie Claude; DiClemente, Ralph J; Brown, Jennifer L; So-Armah, Kaku; Sulkowski, Mark; Marcus, Gregory M; Woolf-King, Sarah; Cook, Robert L; Richards, Veronica L; Molina, Patricia; Ferguson, Tekeda; Welsh, David; Piano, Mariann R; Phillips, Shane A; Stewart, Scott; Afshar, Majid; Page, Kimberly; McGinnis, Kathleen; Fiellin, David A; Justice, Amy C; Bryant, Kendall; Saitz, Richard | Abstract: BackgroundObjective measurement of alcohol consumption is important for clinical care and research. Adjusting for self-reported alcohol use, we conducted an individual participant data (IPD) meta-analysis to examine factors associated with the sensitivity of phosphatidylethanol (PEth), an alcohol metabolite, among persons self-reporting unhealthy alcohol consumption.MethodsWe identified 21 eligible studies and obtained 4073 observations from 3085 participants with Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) positive scores (≥3 for women and ≥4 for men) and PEth measurements. We conducted 1-step IPD meta-analysis using mixed effects models with random intercepts for study site. We examined the associations between demographic (sex, race/ethnicity, and age) and biologic (body mass index-BMI, hemoglobin, HIV status, liver fibrosis, and venous versus finger-prick blood collection) variables with PEth sensitivity (PEth≥8nng/ml), adjusting for the level of self-reported alcohol use using the AUDIT-C score.ResultsOne third (31%) of participants were women, 32% were African, 28% African American, 28% White, and 12% other race/ethnicity. PEth sensitivity (i.e., ≥8nng/ml) was 81.8%. After adjusting for AUDIT-C, we found no associations of sex, age, race/ethnicity, or method of blood collection with PEth sensitivity. In models that additionally included biologic variables, those with higher hemoglobin and indeterminate and advanced liver fibrosis had significantly higher odds of PEth sensitivity; those with higher BMI and those living with HIV had significantly lower odds of PEth sensitivity. African Americans and Africans had higher odds of PEth sensitivity than whites in models that included biologic variables.ConclusionsAmong people reporting unhealthy alcohol use, several biological factors (hemoglobin, BMI, liver fibrosis, and HIV status) were associated with PEth sensitivity. Race/ethnicity was associated with PEth sensitivity in some models but age, sex, and method of blood collection were not. Clinicians should be aware of these factors, and researchers should consider adjusting analyses for these characteristics where possible.

PrEP delivery and routine care provide a unique opportunity to promote sexually transmitted infection (STI) prevention by both increasing STI testing frequency and creating a space for affirmative and effective safer sex counseling. This study was a feasibility and acceptability pilot of an adapted framed message intervention to increase condom use frequency with PrEP. In the formative phase, two focus groups with PrEP users (N = 7) provided feedback on a provisional loss-framed message intervention and identified potential study barriers. In the pilot trial, the adapted loss-framed message intervention was compared to a gain-framed message intervention and enhanced skills condition in a sample of PrEP users (N = 29). In terms of intervention feasibility, 58% of approached PrEP users completed the eligibility screen; 79% of those eligible enrolled in the study and 66% of enrolled participants completed the three-month follow-up. In terms of intervention acceptability, participants found the informational messages, regardless of assignment, to be moderately interesting (M = 6.24, SD = 2.97) and useful (M = 7.07, SD = 3.00), and very easy to understand (M = 9.50, SD = 0.97) on Likert-type scales ranging from 1 to 10. In terms of intervention effects, there was a small effect of the gain-framed intervention (b = .58, SE = .93, CI = -1.33, 2.48, Cohen’s d = .26) on HIV/STI risk transmission. There was a small-medium effect of both the loss- (b = 2.00, SE = .90, CI = .15, 3.85, Cohen’s d = 1.46) and gain-framed (b = 2.24, SE = .93, CI = .34, 4.15, Cohen’s d = 1.65) interventions on condom use motivation. Finally, there was a medium-large effect of both the loss- (b = .97, SE = 1.33, CI = -1.88, 3.82, Cohen’s d = .54) and gain-framed intervention (b = 1.97, SE = 1.33, CI = -.88, 4.82, Cohen’s d = .87) on condom use frequency. Further refinement and testing, in a larger -scale trial with higher ecological validity than this initial pilot intervention, is warranted.

The purpose of this study was to assess the relationship between financial resources strain and self-reported ART adherence among men who have sex with men (MSM) who are living with HIV. Secondary data analyses were conducted with a sample of HIV-positive MSM (N = 77) who participated in a daily diary study on substance use and sexual behavior. Logistic regression was used to model the odds of self-reported ART adherence associated with financial resources strain. The adjusted model revealed a significant association between financial resources strain and self-reported ART adherence such that financially strained participants were 78.4% less likely to have "excellent" self-reported adherence ability compared with non-financially strained participants (aOR = .216, 95% CI [.063, .749], p = .016). Financial resources strain may negatively influence ART adherence. Future research should consider objectively measuring ART adherence. Health care providers might consider assessing patients' financial situation to identify those at-risk for nonadherence.

Alcohol consumption is one of the most prevalent correlates of antiretroviral therapy (ART) adherence, yet causal processes underlying this association remain largely unexplored. The goal of this systematic review was to develop a conceptual model that describes the causal effect of alcohol consumption on ART nonadherence. We reviewed 230 studies that examined the association between alcohol consumption and ART adherence with three primary aims: (1) to replicate and extend previous reviews of the literature, (2) to summarize and critique study designs capable of answering questions about temporal overlap and (3) to summarize potential mechanisms of action. A model of alcohol-associated ART nonadherence was proposed to guide future work, integrating general theories of ART adherence and theory on the psychological and behavioral effects of alcohol intoxication. The conceptual model describes two mechanistic processes-prospective memory impairment and interactive toxicity beliefs/avoidance behaviors-involved in alcohol-associated intentional and unintentional nonadherence, respectively. This model can be used to guide future research on the causal processes involved in the frequently observed correlation between alcohol consumption and adherence.

Understanding the mental health outcomes of sexual assault among college women is a public health priority. Although research has identified risk factors for the development of mental health problems following an assault, few studies have utilized a strengths-based approach to identify personal and social resources that may mediate the sexual assault–mental health link. Prior studies allude to the role of resilience and perceived campus belonging in explaining the relationship between sexual assault and mental health. This study represents the first application of the stress process model using a large sample of college women to examine (a) the association between sexual assault and mental health (i.e., psychological distress, suicidality, self-harm) and alcohol use problems and (b) the role of resilience and perceived campus belonging as partial mediators of these associations. Data were collected as part of the Spring 2021 American College Health Association National College Health Assessment (ACHA-NCHA; n = 31,328, Mean age = 20.26, SD = 1.64, 58.8% White), a cross-sectional, online survey that samples college students from 143 self-selected United States colleges. To test our primary hypothesis, a structural regression model was conducted, which included a latent sexual assault predictor, manifest resilience and campus belonging mediators, a latent mental health outcome, and a manifest alcohol use problems outcome. Mental health and alcohol use problems were positively associated with sexual assault and negatively associated with resilience and campus belonging. Resilience partially mediated the association between sexual assault and mental health. Campus belonging partially mediated the association between sexual assault, mental health, and alcohol use problems. This model explained 23.2% of the variance in mental health and 5.9% of the variance in alcohol use. Resilience and campus belonging may represent modifiable factors that can be targeted in trauma-focused interventions in efforts to improve victimized college women’s mental health.

Unhealthy alcohol use fuels difficulties with HIV disease management and potentiates secondary transmission of HIV but less is known about how these alcohol use expectancies may shape alcohol use behaviors, particularly in the presence of depressive symptomatology. In this paper, we utilize data from a prospective study of 208 people living with HIV in Southwest Uganda, to examine the correlates of alcohol use expectancies and their association with unhealthy alcohol use. Affective depressive symptoms were positively associated with alcohol use expectancies. Gender moderation was observed such that depression was more strongly associated with alcohol use expectancies among women. In unadjusted analyses, alcohol use expectancies were marginally associated with unhealthy alcohol use and this association was not significant in adjusted analyses. Findings underscore the need to strengthen screening for depression and alcohol use within HIV care services, particularly among women.

Background Self-report is widely used to assess alcohol use in research and clinical practice, but may be subject to social desirability bias. We aimed to determine if social desirability impacts self-reported alcohol use. Methods Among 751 human immunodeficiency virus (HIV)-infected patients from a clinic in southwestern Uganda, we measured social desirability using the Marlowe-Crowne Social Desirability Scale (SDS) Short Form C, self-reported alcohol use (prior 3 months) Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), and phosphatidylethanol (PEth), a biomarker of prior 3 weeks' drinking. We conducted multiple regression analyses to assess the relationship between SDS score (low, medium, and high levels) and (i) any self-reported recent alcohol use, among those who were PEth-positive (≥8 ng/ml), and (ii) continuous AUDIT-C score, among those reporting any recent alcohol use. We controlled for PEth level, age, gender, education, economic assets, marital status, religion, spirituality/religiosity, social support, and study cohort. Results Of 751 participants, 59% were women; the median age was 31 years (interquartile range [IQR]: 26 to 39). Median SDS score was 9 (IQR: 4 to 10). Two-thirds (62%) self-reported any recent alcohol use; median AUDIT-C was 1 (IQR: 0 to 4). Among those who were PEth-positive (57%), 13% reported no recent alcohol use. Those with the highest SDS tertile had decreased odds of reporting any recent alcohol use compared to the lowest tertile, but the association did not reach statistical significance in multivariable analyses (adjusted odds ratio 0.55 [95% confidence interval (CI): 0.25, 1.23]). Among participants self-reporting recent alcohol use, SDS level was negatively associated with AUDIT-C scores (adjusted β: -0.70 [95% CI: -1.19, -0.21] for medium vs. low SDS and -1.42 [95% CI: -2.05, -0.78] for high vs. low SDS). Conclusions While use of objective measures (e.g., alcohol biomarkers) is desirable for measuring alcohol use, SDS scores may be used to adjust self-reported drinking levels by participants' level of social desirability in HIV research studies.

Sexual and gender minority youth (SGMY) are disproportionately affected by mental health problems, including depression and suicidality. Recently, there has been increased interest in developing an...

Diagnosis of CHD substantially affects parent mental health and family functioning, thereby influencing child neurodevelopmental and psychosocial outcomes. Recognition of the need to proactively support parent mental health and family functioning following cardiac diagnosis to promote psychosocial adaptation has increased substantially over recent years. However, significant gaps in knowledge remain and families continue to report critical unmet psychosocial needs. TheParent Mental Health and Family Functioning Working Groupof the Cardiac Neurodevelopmental Outcome Collaborative was formed in 2018 through support from an R13 grant from the National Heart, Lung, and Blood Institute to identify significant knowledge gaps related to parent mental health and family functioning, as well as critical questions that must be answered to further knowledge, policy, care, and outcomes. Conceptually driven investigations are needed to identify parent mental health and family functioning factors with the strongest influence on child outcomes, to obtain a deeper understanding of the biomarkers associated with these factors, and to better understand how parent mental health and family functioning influence child outcomes over time. Investigations are also needed to develop, test, and implement sustainable models of mental health screening and assessment, as well as effective interventions to optimise parent mental health and family functioning to promote psychosocial adaptation. The critical questions and investigations outlined in this paper provide a roadmap for future research to close gaps in knowledge, improve care, and promote positive outcomes for families of children with CHD.

Men who have sex with men (MSM) account for more than two thirds of new HIV diagnoses annually. Sexual behavior that increases risk for onward transmission of HIV is associated with both alcohol and cannabis use. However, little is known about the influence of cannabis and alcohol co-use on engagement in condomless anal sex (CAS). The current study explored daily associations between substance use and CAS among HIV-positive MSM using a 42-day Timeline Followback interview (N=101). Generalized estimating equation (GEE) logistic regression models were used to examine the association between cannabis and alcohol co-use and CAS at the sexual event while controlling for study site, condition, adherence to antiretroviral therapy, sex-related alcohol expectancies, and partner type. Participants provided data for 1,052 sexual activity days, 60.7% of which involved CAS. Of 638 CAS days, 9.1% involved no substances, 72.0% involved either cannabis or alcohol use, and 18.9% involved cannabis and alcohol co-use. Results indicated that the odds of engaging in CAS were higher for sexual events in which cannabis and alcohol co-use occurred (aOR = 2.98; 95% CI: 1.27, 6.97) compared to events in which no substance use occurred (p = .012), but this relationship was no longer significant when cannabis and alcohol co-use was compared to single substance use (aOR = 1.57; 95% CI: 0.85, 2.90; p = .15). Future research should identify specific substance use (e.g., quantity) and partner characteristics (e.g., level of intoxication) that may uniquely influence the relationship between cannabis and alcohol co-use and condomless sex.

Hazardous drinking by persons living with HIV (PLHIV) is a well-established determinant of sub-optimal HIV care and treatment outcomes. Despite this, to date, few interventions have sought to reduce hazardous drinking among PLHIV in sub-Saharan Africa (SSA). We describe an iterative cultural adaptation of an evidence-based multi-session alcohol reduction intervention for PLHIV in southwestern Uganda. The adaptation process included identifying core, theoretically informed, intervention elements, and conducting focus group discussions and cognitive interviews with community members, HIV clinic staff and patients to modify key intervention characteristics for cultural relevance and saliency. Adaptation of evidence-based alcohol reduction interventions can be strengthened by the inclusion of the target population and key stakeholders in shaping the content, while retaining fidelity to core intervention elements.

This study gathered preliminary data on the impact of the U.S. response to the COVID-19 pandemic on the substance use, sexual behavior, and general well-being of U.S. college students. Participants from colleges across the U.S. (N = 212; 50.5% female; M age = 22.09) completed an online survey between May 20th and July 5th, 2020 about COVID-19-related behavior change. Most students reported a decrease in quality of life (71.7%), an increase in levels of anxiety (63.7%), and problems with basic resource needs (53.8%). Reports of alcohol consumption increased for 26.9% of students and 15.1% reported an increase in cannabis use. Most students (57.5%) reported a decrease in sexual activity, yet access to, and use of, condoms generally remained unchanged. As universities resume residential instruction, existing prevention and intervention services will need to be adapted to address the mental and behavioral health needs of college students during the era of COVID-19.

Although there is evidence of individual associations between depressive symptoms and hazardous alcohol use with suboptimal antiretroviral therapy (ART) adherence among people living with HIV (PLWH), few studies have established how the two risk factors may interact to predict viral suppression. We conducted secondary data analyses with two cohorts of Ugandan PLWH (N = 657) to investigate the hypothesized interaction between depressive symptoms (Center for Epidemiological Studies Depression Scale) and hazardous alcohol use (Alcohol Use Disorder Identification Test -Consumption and/or Phosphatidylethanol biomarker) prior to ART initiation with viral suppression (

Alcohol use is a significant problem in HIV care, and clinical trials of alcohol interventions for people living with HIV infection (PLWH) have produced mixed results. The purpose of this qualitative study was to collect preliminary data on the practical feasibility and acceptability of Acceptance and Commitment Therapy (ACT) as a treatment for PLWH who are hazardous drinkers. A total of 25 PLWH participated in individual interviews. Four major themes emerged from the thematic analysis: (I) Perceived Appropriateness for PLWH and People who use Alcohol and/or other Substances, (II) General Satisfaction and Dissatisfaction, (III) Positive and Negative Effects on Participants and (IV) Facilitators and Barriers to Implementing ACT Intervention Strategies.

Objective: The HIV literature has largely ignored the importance of alcohol use in the quality of intimate relationships in sub-Saharan Africa (SSA), despite evidence of alcohol’s role in relational behaviors that increase risk for HIV infection and other harms. The present study explored the association of alcohol use with relationship functioning among heterosexual couples from rural South Africa. Method: Dyadic analyses were conducted with 443 sexually active, heterosexual, South African couples (886 individuals) to examine the association between male partners’ alcohol use (abstinent, nonhazardous, and hazardous), and male and female partners’ reports of relationship intimacy, trust, mutually constructive communication, demand/withdraw communication, and satisfaction. Five structural equation models were fit using male partner alcohol use as a predictor of male and female reports of relationship quality. Results: Women with a hazardous-drinking male partner (compared to an abstainer) reported significantly higher levels of intimacy (p Conclusions: Hazardous alcohol use among South African couples is positively correlated with women’s relationship intimacy and maladaptive communication patterns, yet negatively correlated with men’s perceived trust.

Viral suppression, a critical component of HIV care, is more likely when individuals initiate antiretroviral therapy (ART) early in disease progression and maintain optimal levels of adherence to ART regimens. Although several studies have documented the negative association of depressive symptoms with ART adherence, less is known about how depressed mood relates to intentional versus unintentional lapses in adherence as well as the mechanisms underlying this association. The purpose of the current study was to examine the association of depressive symptoms with ART adherence, assessed as a multidimensional construct. Secondarily, this study conducted preliminary indirect path models to determine if medication self-efficacy could explain the depressed mood-adherence relationship. Depressive symptoms were not associated with 95% ART taken, self-reported viral load, deliberate adjustments to ART regimens or skipped ART doses. However, the indirect association of depressive symptoms via decrements in medication self-efficacy was significant for 95% ART taken, self-reported viral load and skipped ART doses, but not deliberate changes to ART regimens. In this sample of HIV-positive outpatients, there is evidence to support medication self-efficacy as a potential mechanism underlying the association between depressive symptoms and ART adherence. Additional longitudinal studies are needed to formally examine medication taking self-efficacy as a mediator.

OBJECTIVE: To develop and apply a method to quantify bias parameters in the case example of the association between alcohol use and HIV-serodiscordant condomless anal sex with potential confounding by sensation seeking among men who have sex with men (MSM), using expert opinion as an external data source. METHODS: Through an online survey, we sought the input of 41 epidemiologist and behavioural scientists to quantify six parameters in the population of MSM: the proportion of high sensation seeking among heavy-drinking MSM, the proportion of sensation seeking among low-level drinking MSM, and the risk ratio (RR) of the association between sensation seeking and condomless anal sex, for HIV-positive and HIV-negative MSM. RESULTS: Eleven experts responded. For HIV-positive heavy drinkers, the proportion of high sensation seeking was 53.6% (beta distribution [ α =5.50, β =4.78]), and 41.1% (beta distribution [ α =3.10, β =4.46]) in HIV-negative heavy drinkers. In HIV-positive low-level alcohol drinkers, high sensation seeking was 26.9% (beta distribution [ α =1.81, β =4.92]), similar to high sensation seeking among HIV-negative low-level alcohol drinkers (25.3%) (beta distribution [ α =2.00, β =5.89]). The lnRR for the association between sensation seeking and condomless anal sex was ln(2.4) (normal distribution [ μ =0.889, σ =0.438]) in HIV-positive and ln(1.5) (normal distribution [ μ =0.625, σ =0.391]) in HIV-negative MSM. CONCLUSION: Expert opinion can be a simple and efficient method for deriving bias parameters to quantify and adjust for hypothesized confounding. In this test case, expert opinion confirmed sensation seeking as a confounder for the effect of alcohol on condomless anal sex and provided the parameters necessary for probabilistic bias analysis.

Author(s): Woolf-King, Sarah E; Arnold, Emily; Weiss, Sandra; Teitel, David | Abstract: AIMS AND OBJECTIVES:The purpose of this study was to explore the psychological impact of parenting a child with a critical congenital heart defect and the feasibility and acceptability of integrating psychological services into paediatric cardiology care. BACKGROUND:Children with critical congenital heart defect are at an increased risk for long-term behavioural, social and emotional difficulties. Data suggest that this risk is partially attributable to parental mental health, which is a stronger predictor of long-term behavioural problems in congenital heart defect children than disease-specific and surgical factors. Parental stress and mental health are thus important intervention targets, especially among high-risk families. DESIGN:This article presents data from a qualitative study with 25 congenital heart defect parents (nn=n15) and providers (nn=n10). METHODS:Using thematic analysis, semi-structured in-depth interviews were transcribed and coded by the first and second author to identify major themes and subthemes. RESULTS:Results of the interviews were organised into four major themes: (i) the psychological impact of parenting a child with critical congenital heart defect, (ii) factors that influence the psychological impact of parenting a child with critical congenital heart defect, (iii) how and when to psychologically support congenital heart defect parents and (iv) feasibility and acceptability of integrating psychological support into congenital heart defect care. Providers and parents endorsed the integration of mental health treatment into routine congenital heart defect care and identified several practical issues related to feasibility (e.g., funding and space) that should be considered prior to implementation. CONCLUSIONS:Parents of children with critical congenital heart defect need access to mental health services, and integrating these services into routine paediatric cardiology care is a novel and practical way for parents to receive the treatment they need. RELEVANCE TO CLINICAL PRACTICE:Suggestions for how the field of paediatric cardiology could begin to integrate mental health services into congenital heart defect treatment are provided.

The practical feasibility of using prostate specific antigen (PSA) as a biomarker of semen exposure was examined among HIV-infected Ugandan women. Vaginal fluids were obtained with self-collected swabs and a qualitative rapid test (ABAcard®p30) was used to detect PSA. Trained laboratory technicians processed samples on-site and positive PSA tests were compared to self-reported unprotected vaginal sex (UVS) in the last 48h. A total of 77 women submitted 126 samples for PSA testing at up to three study visits. Of these samples, 31% (n=39/126) were PSA positive, and 64% (n=25/39) of the positive PSA samples were accompanied by self-report of no UVS at the study visit the PSA was collected. There were no reported difficulties with specimen collection, storage, or processing. These findings provide preliminary data on high levels of misreported UVS among HIV-infected Ugandan women using practically feasible methods for PSA collection and processing.

Interactive toxicity beliefs regarding mixing alcohol and antiretroviral therapy (ART) may influence ART adherence. HIV-infected patients in Uganda completed quarterly visits for 1year, or one visit at 6months, depending on study randomization. Past month ART non-adherence was less than daily or

Unhealthy alcohol use is a crucial driver of HIV in sub-Saharan Africa, and interventions are needed. The goal of this study was to assess whether assessment itself (assessment reactivity) causes declines in alcohol use in a research study in persons with HIV in Uganda.Study participants were adult patients of the Immune Suppression Syndrome (ISS) Clinic in Mbarara, Uganda, who were new to HIV care and reported any alcohol consumption in the prior year. Participants were randomized to (a) a study cohort, with structured interviews, breath alcohol analysis tests, and blood draws conducted quarterly, or (b) a minimally assessed arm that engaged in these procedures only once, at 6 months after baseline. The main outcome was unhealthy drinking at 6 months, defined as Alcohol Use Disorders Identification Test-Consumption [AUDIT-C] positive (≥3 for women, ≥4 for men) or phosphatidylethanol (PEth; an alcohol biomarker) level ≥ 50 ng/ml. We also examined this outcome stratified by gender.We examined 175 and 139 persons in the quarterly assessed versus minimally assessed arms, respectively. Overall, 54.8% were male, the median age was 30 (interquartile range: 25-36), and 58.0% initiated anti-retroviral therapy at 6 months. Nearly equal proportions (53.7% and 51.1% in the study quarterly assessed vs. minimally assessed arm, respectively) engaged in unhealthy drinking in the 3 months before the 6-month study visit (p = .64), and we found no evidence of interaction by gender (p = .36).We found no evidence of assessment reactivity in a study that included quarterly study visits. Assessment is not sufficient to act as an intervention itself in this population with high levels of unhealthy drinking. Interventions are needed to decrease alcohol consumption in this population.

While alcohol is a known risk factor for HIV infection in sub-Saharan Africa (SSA), studies designed to investigate the temporal relationship between alcohol use and unprotected sex are lacking. The purpose of this study was to determine if alcohol used at the time of a sexual event is associated with unprotected sex at that same event. Data for this study were collected as part of two longitudinal studies of HIV-infected Ugandan adults. A structured questionnaire was administered at regularly scheduled cohort study visits in order to assess the circumstances (e.g., alcohol use, partner-type) of the Most Recent Sexual Event (MRSE). Generalized estimating equation (GEE) logistic regression models were used to examine the association between alcohol use (by the participant, the sexual partner, or both the participant and the partner) and the odds of unprotected sex at the sexual event while controlling for participant gender, age, months since HIV diagnosis, unhealthy alcohol use in the prior 3 months, partner-type, and HIV status of partner. A total of 627 sexually active participants (57% women) reported 1,817 sexual events. Of these events, 19% involved alcohol use and 53% were unprotected. Alcohol use by one’s sexual partner (aOR) = 1.70; 95%CI = 1.14, 2.54) or by both partners (aOR: 1.78; 95%CI: 1.07, 2.98), during the MRSE significantly increased the odds of unprotected sex at that same event. These results add to the growing event-level literature in SSA and support a temporal association between alcohol used prior to a sexual event, and subsequent unprotected sex.

Background Parents of children with critical congenital heart defects ( PCCHD s) may be at high risk for mental health morbidity; however, the literature is not well characterized. Given that compromised parental mental health can lead to long‐term cognitive, health‐related, and behavioral problems in children, a systematic review of this literature could provide informed recommendations for continued research and enhance the care of families of children living with critical congenital heart defects. Methods and Results We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines that resulted in 30 studies on the mental health of PCCHD s. The literature revealed that PCCHD s are at an elevated risk for psychological problems, particularly in the immediate weeks and months following cardiac surgery. Up to 30% of PCCHD s have symptoms consistent with a diagnosis of posttraumatic stress disorder, with over 80% presenting with clinically significant symptoms of trauma; 25% to 50% of PCCHD s reported clinically elevated symptoms of depression and/or anxiety, and 30% to 80% reported experiencing severe psychological distress. There was high variability in measurements used to assess study outcomes, methodological quality, and sociocultural composition of the parents included in the studies. Conclusions There is an urgent need for additional research on the severity, course, persistence, and moderators of these mental health problems over time, and for the development and testing of screening approaches and interventions that can be feasibly delivered in the context of ongoing pediatric cardiac care.

African American adults are disproportionately affected by HIV in the United States, underscoring the need for additional research on barriers to condom use. Guided by the theory of gender and power, this experimental study used a series of vignettes to test causal hypotheses regarding the influence of event-level alcohol use (present and absent), partner type (serious and casual), and relationship power (low and equal) on perceived difficulty implementing condom use. A total of 299 (151 women and 148 men) heterosexual African American adults indicated how “difficult” it would be to use a condom after reading 8 hypothetical sexual encounters, presented in a random order. A 2 x 2 x 2 x 2 repeated measures analysis of covariance (ANCOVA) with one between subjects factor (gender) and one covariate (condom use self-efficacy) was used to estimate the effects of these variables on an index of perceived difficultly. The women in the study reported significantly higher ratings of difficulty implementing condom use in vignettes characterized by low relationship power (p < .001) and presence of alcohol use (p < .001); the manipulated independent variables did not produce any main effects for men. Both men and women’s ratings of perceived difficulty decreased as condom use self-efficacy increased (p < .001). This is the first study to use an experimental methodology to test hypotheses about barriers to condom use among a community-based sample of African American adults. These data can be used to enhance existing HIV prevention interventions.

Woolf-King, S., Steinmaus, C. M., Reingold, A. L. & Hahn, J. A. (2013). An update on alcohol use and risk of HIV infection in sub-Saharan Africa: Meta-analysis and future research directions. International Journal of Alcohol and Drug Research, 2(1) , 99-110. doi: 10.7895/ijadr.v2i1.45 ( http://dx.doi.org/10.7895/ijadr.v2i1.45 ) Aims: Sub-Saharan Africa is disproportionately affected by HIV/AIDS, and growing evidence suggests that alcohol consumption is a co-occurring problem in the region. We conducted a meta-analysis on studies of alcohol use and HIV infection in sub-Saharan Africa in order to assess associations, evaluate heterogeneity in the literature, identify susceptible subgroups, and suggest avenues for future research. Design: We performed a systematic review, including published review articles and electronic database searches, and identified 35 studies on alcohol use and HIV. Setting and participants: All of the studies included in the meta-analysis occurred with adults in sub-Saharan Africa. Measurements: Pooled odds ratio ( OR ) estimates were calculated using both the fixed inverse variance weighting method and the random effects method when evidence of heterogeneity was present. Findings: The pooled OR estimate for all studies was 1.61 (95% CI: 1.44–1.80). The association between alcohol use and prevalence or incident HIV infection was particularly large among samples who reported problem drinking ( OR = 2.17, 95% CI: 1.64–2.87) and drinking in sexual contexts ( OR = 1.79, 95% CI: 1.55–2.06). Some evidence of publication bias was present; however, the OR remained statistically significant in small and large studies and with population-based and high-risk samples. Conclusions: These results suggest that alcohol consumption, particularly at high levels and in sexual contexts, is associated with an increased risk of HIV infection. An increased focus on methods that allow for more sensitive tests of the event-level association between alcohol consumption and risk of HIV infection may provide a better understanding of the causal mechanisms underlying this relationship.

Primary prevention efforts aimed at sexual risk behaviors are critical. This experiment was designed to investigate the effects of alcohol intoxication and sexual arousal, as well as person variables of alcohol sex expectancies and attitudes toward condom use, on hypothesized determinants of sexual risk behaviors among men who have sex with men (MSM). The participants were 117 MSM aged 21–50 years who were randomly assigned to one of six separate experimental conditions created by the combination of beverage administration (water control, placebo or alcohol designed to raise blood alcohol level to .07%) and sexual arousal (low or high, manipulated by participants’ viewing non-erotic or mildly erotic film clips). Participants attended two experimental sessions. The first session included completing questionnaires about beliefs about alcohol’s effects on sex and attitudes toward condoms’ effect on sexual pleasure. The second session involved the beverage condition and arousal manipulations. Following these, participants viewed and responded to two interactive videos depicting high sexual risk scenarios. Participants also completed the CARE, a measure of risk perceptions. The dependent variables were behavioral skills, intentions to have unsafe sex, and “risk exposure,” derived from responses to the videos. The results of both planned and exploratory analyses showed general support for the hypothesized enhancement of alcohol’s effects on sexual risk by both sexual arousal and expectancies. Also as predicted, condom attitudes showed direct relationships to risk exposure and intentions. Implications of the findings for models of alcohol’s effects on sexual risk and for the development of HIV prevention interventions were discussed.

Alcohol consumption adds fuel to the HIV epidemic in sub-Saharan Africa (SSA). SSA has the highest prevalence of HIV infection and heavy episodic drinking in the world. Alcohol consumption is associated with behaviors such as unprotected sex and poor medication adherence, and biological factors such as increased susceptibility to infection, comorbid conditions, and infectiousness, which may synergistically increase HIV acquisition and onward transmission. Few interventions to decrease alcohol consumption and alcohol-related sexual risk behaviors have been developed or implemented in SSA, and few HIV or health policies or services in SSA address alcohol consumption. Structural interventions, such as regulating the availability, price, and advertising of alcohol, are challenging to implement due to the preponderance of homemade alcohol and beverage industry resistance. This article reviews the current knowledge on how alcohol impacts the HIV epidemic in SSA, summarizes current interventions and policies, and identifies areas for increased research and development.

Experimental research on sexual decision making is limited, despite the public health importance of such work. We describe formative work conducted in advance of an experimental study designed to evaluate the effects of alcohol intoxication and sexual arousal on risky sexual decision making among men who have sex with men. In Study 1, we describe the procedures for selecting and validating erotic film clips (to be used for the experimental manipulation of arousal). In Study 2, we describe the tailoring of two interactive role-play videos to be used to measure risk perception and communication skills in an analog risky sex situation. Together, these studies illustrate a method for creating experimental stimuli to investigate sexual decision making in a laboratory setting. Research using this approach will support experimental research that affords a stronger basis for drawing causal inferences regarding sexual decision making.

The original version of this article unfortunately contained a mistake in Fig. 1. The figure was incorrectly presented with the results of an additional path model for forgotten antiretroviral therapy (ART) doses that was dropped from the primary analyses.

Alcohol has a substantial negative impact on the HIV epidemic in sub-Saharan Africa, particularly in Uganda, where heavy alcohol consumption is common. Using a content analytic approach, this qualitative study characterizes changes in alcohol use among 59 HIV-infected Ugandan adults (>18years old), who reported any alcohol use in the previous year as they entered HIV care. Most participants reported attempting to cease or reduce alcohol intake over the study period. Reasons for decreased use included advice from clinicians, interference with social obligations, threats to financial security, and negative impact on social standing. Participants reported difficulty abstaining from alcohol, with incentives to continue drinking including desire for social inclusion, stress relief, and enjoyment of alcohol. These contrasting incentives created a moral quandary for some participants, who felt 'pulled' between 'good' and 'bad' influences. Results suggest brief interventions addressing self-identified obstacles to change may facilitate long-term reductions in drinking in this population.

ObjectiveThe purpose of this study was to develop and validate the East Africa Alcohol Expectancy Scale (AFEXS), a measure of alcohol expectancies for use with HIV-positive adults in East Africa.MethodThe study was conducted in several phases. The first involved development of the scale and an exploratory factor analysis (EFA) with a total of 209 HIV-positive, Ugandan men (n = 120) and women (n = 89). The second phase involved a confirmatory factor analysis (CFA) as well as validity analyses with a second, demographically similar, sample of 181 HIV-positive Ugandan men (n = 109) and women (n = 72). All participants were recruited from two ongoing cohort studies taking place at an HIV clinic in rural southwestern Uganda.ResultsThe EFA resulted in a 13-item, three-factor scale that explained 67% of the variance and showed excellent internal consistency (α = .89). The CFA showed good model fit with a final 11-item scale, χ(2)(41) = 68.60, p = .004; comparative fit index = .97; root mean square error of approximation = .06, 90% CI [.03, .09], that again showed excellent internal consistency and yielded the following three factors: sex-related (α = .94), release of inhibition (α = .61), and negative expectancies (α = .73).ConclusionsThe AFEXS is the first psychometrically validated alcohol expectancy scale available for use in Africa. The extent to which the AFEXS can be used with other populations and with adults from countries outside of East Africa requires ongoing validation.

BACKGROUND Substance use is strongly linked to HIV risk, and members of couples can have a powerful influence on each other's health behaviors. We examined whether couple-level patterns of stimulant use were differentially associated with engaging in condomless anal intercourse with primary partners and outside partners. METHODS Members of HIV serodiscordant male couples (N = 117 couples, 232 men) completed surveys, and HIV-positive men had blood drawn for viral load. RESULTS Results revealed that stimulant use by only one partner in the couple was associated with a decrease in the odds of engaging in condomless anal sex with one's primary partner (AOR = 0.09, 95% CI: 0.01, 0.89). When both partners reported stimulant use, the HIV-negative partner had an increase in the odds of condomless sex with outside partners (AOR = 6.68, 95% CI: 1.09, 8.01). CONCLUSIONS Understanding the role of couples' stimulant use patterns in HIV transmission risk is an important area for future research and intervention.

BackgroundResearch conducted to date has focused primarily on identifying individual-level, psychological determinants of stimulant use and HIV disease management. The present cross-sectional study examined relationship factors as correlates of stimulant use and HIV disease management among men who have sex with men (MSM).MethodsIn total, 266 male couples completed a baseline assessment for a cohort study examining the role of relationship factors in HIV treatment. A computer-based assessment of relationship factors, self-reported alcohol and substance use, and self-reported anti-retroviral therapy (ART) adherence was administered. All HIV-positive participants also provided a blood sample to measure viral load.ResultsAfter controlling for demographic characteristics and relationship factors, men in a primary relationship with a stimulant-using partner had more than six-fold greater odds of reporting any stimulant use in the past three months. Among HIV-positive participants on ART (n=371), having a stimulant-using partner was independently associated with 67% lower odds of reporting perfect 30-day ART adherence and more than two-fold greater odds of displaying a detectable HIV viral load. In contrast, more partner-level alcohol use was independently associated with greater odds of reporting perfect 3-day ART adherence and lower odds of displaying a detectable HIV viral load.ConclusionsPartner-level stimulant use is an important risk factor for individual-level stimulant use and difficulties with HIV disease management among MSM. To optimize the effectiveness of HIV treatment as prevention, clinical research is needed to develop couples-based interventions targeting stimulant use as a potential driver of detectable HIV viral load.

Alcohol use among HIV-positive (HIV+) individuals is associated with decreased adherence to antiretroviral therapy (ART) and consequently poorer HIV treatment outcomes. This study examined the independent association of individual and partner-level alcohol use with HIV disease management among men who have sex with men (MSM) in primary partnerships. In total, 356 HIV+ MSM and their male primary partners completed a baseline visit for a longitudinal study examining the role of couple-level factors in HIV treatment. The Alcohol Use Disorders Identification Test (AUDIT) was administered to assess the individual and the partner-level alcohol use. Primary outcome variables included self-reported ART adherence, ART adherence self-efficacy, and HIV viral load. Results demonstrated that abstainers, compared to hazardous drinkers, had higher self-efficacy to integrate and persevere in HIV treatment and a lower odds of having a detectable viral load. Participants with a partner-abstainer, versus a partner-hazardous drinker, had less self-efficacy to persevere in HIV treatment, a lower odds of 100% three-day adherence and a higher viral load. Together, these findings suggest that assessment and treatment of both the patient's and the patient's primary partner's pattern of alcohol consumption is warranted when attempting to optimize HIV care among MSM.

Sub-Saharan Africa (SSA) contains 10% of the world’s population and 60% of all people living with AIDS. Consequently, research investigating risk factors associated with HIV acquisition is a public health priority and one such risk factor is alcohol consumption. This article is a review of empirical studies on the association of alcohol and high-risk sexual behavior in SSA, with a focus on measurable outcomes generated from quantitative data. A critique of the literature is provided, with attention to methodological concerns. Empirically based theoretical orientations were used to interpret the reviewed research and to stimulate discussion about how to improve the state of the current literature. Based on this discussion, a model of alcohol and high-risk sexual behavior in an African context is proposed in order to integrate the existing literature and highlight areas in need of continued research.