VACS Scientific Meeting Houston, TX February 2004 Predictors of Risky Sexual Behavior among Veterans with and without HIV Infection: Results from VACS 5 VACS Scientific Meeting Houston, TX February 2004 Robert L. Cook MD, MPH University of Pittsburgh

Sexual Behavior Writing Group Robert Cook Kevin Kraemer Adam Gordon Joseph Conigliaro Kathleen McGinnis Tamra Maidenwald Jeffrey Samet Stephen Maisto Stephen Crystal David Rimland Kendall Bryant Amy Justice

Risky sexual behavior among persons with HIV is an important public health issue.

Health care providers may be able to intervene with their HIV-infected patients to prevent the spread of HIV to others

VACS is planning a future intervention VACS is planning a future intervention. We wondered, what kind of health system intervention could lead to a reduction in risky sexual behavior among persons with HIV infection? Would a substance-abuse related intervention be effective?

Research Questions Is risky sexual behavior common among persons attending VA Hospital clinics?

Research Questions Is risky sexual behavior common among persons attending VA Hospital clinics? How does risky behavior differ according to demographic characteristics or HIV-infection status?

Research Questions Is risky sexual behavior common among persons attending VA Hospital clinics? How does risky behavior differ according to demographic characteristics or HIV-infection status? Are specific patterns of alcohol/drug use more strongly linked to risky sexual behavior than others?

Study Population 1746 Participants in VACS-5 (Feasibility Study) Recruited in 2001-2002 from five VA Hospitals: Atlanta, Bronx, Brooklyn /Manhattan, Houston, LA Infectious Disease Clinics (n=1018) all provider-approved HIV+ patients eligible General Medicine Clinics (n=728) HIV- persons matched for age, race and site > 80% of those approached enrolled in the study

Key features of VACS 5 Cross-sectional study Includes persons with and without HIV infection. Includes mostly men. Expanded measures of substance abuse. Limited measures of risky sexual behavior.

Risky Sexual Behavior Measures Number of sex partners During the past 12 months, with how many partners have you had sex? (oral, anal, or vaginal) (0, 1, 2-4, ≥5) Condom use (last intercourse) “the last time you had sex, did you or your partner use a condom?” Multiple sex partners AND no condom 2 or more sex partners and no condom use at last intercourse

Alcohol and Drug Use Measures Quantity/ Frequency 0, 1-14, or ≥ 14 drinks per month AUDIT 10-items (score ≥ 8 suggests alcohol use disorder) Binge ≥ 6 drinks/occasion at least monthly DAST 10-items (Score ≥3 suggests drug use disorder) Injection drug use Current (past 12 months), past, none Intoxicated before sex “The last time you had sexual intercourse were you intoxicated or high from alcohol or drugs?”

Research Question 1: Is risky sexual behavior common among persons attending VA Hospital clinics?

Number of sexual partners (Past 12 months) HIV + (n = 991) HIV – (n = 710) # partners % 1 2-5 ≥ 5 32 22 14 26 54 16 4

Risky Sexual Behavior* HIV + HIV - P Behavior % Did not use condom 27 73 0.00 Multiple partners and no condom - Alcohol/Drug use prior to sex 23 10 * Among sexually active men

Research Question 2: How does risky behavior differ according to demographic characteristics or HIV-infection status?

Factors associated with greater number of sexual partners HIV + HIV - Younger age X Black race Higher income Not married Sex with men Depression

Factors associated with not using a condom (at last intercourse) HIV + HIV - Over age 40 X White race Higher income Married Sex with men

Factors associated with multiple partners and no condom use HIV + HIV - Age ≥ 40 X White race Income Not married Sex with men Depressed Prevalence of behavior among married men: 12% HIV+ 11% HIV- Prevalence of behavior among men >age 60: 16% HIV+ 23% HIV-

Research Question 3: Are specific patterns of alcohol/drug use more strongly linked to risky sexual behaviors than others?

Drug/alcohol variables associated with multiple sex partners (≥ 2) HIV + HIV - Drinks >14 per week X Alcohol abuse (AUDIT) Binge drinking IVDU Drug abuse Intoxicated before sex

Drug/alcohol variables associated with no condom (last intercourse) HIV + HIV - Drinks >14 per week Alcohol abuse Binge drinking IVDU Drug abuse X O Intoxicate before sex O means they were MORE likely to use a condom

Drug/Alcohol variables associated with multiple partners and no condom use HIV + HIV - Drinks >14 per week Alcohol abuse X Binge drinking IVDU Drug abuse Intoxicated before sex

Multivariate Analysis: Significant Predictors of Multiple Sex Partners Men with HIV Infection Odds Ratio (95% CI) African-American 1.5 1.0-2.3 Sex with men 3.8 2.5-5.8 Married/Stable relationship 0.3 0.2-0.4 Intoxicated before last intercourse 2.2 1.3-3.5 * Analysis presented at RSA meeting last year; current results may differ slightly

Limitations Cross-sectional associations. Can not prove cause-effect relationship Our measures of sexual behavior were not precise. These represent self-reported information on stigmatized behaviors. We have not yet completed multivariate analyses.

Conclusions Risky sexual behavior is relatively common in male veterans with HIV infection. 13% had >5 sexual partners in the past year. At least 23% are not using condoms Among persons with HIV, risky sexual behavior appears to be more common among white men who have sex with men A situational measure of alcohol/drug use appears to be more strongly associated with risk of HIV transmission, compared to more traditional measures of consumption or abuse.

VACS: The Future More extensive sexual behavior measures are being collected at one-year follow-up. Clinical outcome measures of STDs. Prospective analyses

Expanded sexual behavior measures include: Any anonymous/casual sex Self-reported STDs Self-reported “did alcohol cause you to have risky sexual behavior” Self-reported “did specific drugs cause you to have risky sexual behavior” Sex-related alcohol expectations

Sexual Behavior Writers Group Breakfast Meeting 8AM Tuesday B.Y.O.B.