Among participants reporting having had vaginal or anal sex in the previous 90 days, 24% reported having had sex without a condom (Table 2).
In the bivariate analysis, factors associated with unprotected anal or vaginal sex in the previous 90 days at the P < 0.10 significance level to be included in the multivariate analysis were: female gender, being partnered or married, race/ethnicity, past 30-day alcohol use, past 30-day heroin use, and hepatitis B surface antibody positivity (data not shown). Age, having some college, lifetime history of alcohol use, lifetime history of nonheroin opiates, hepatitis B core antibody positivity, and being on HAART were inversely associated with unprotected sex (P < 0.10 level) in the bivariate analysis (data not shown). In multivariate analysis, having a partner, female gender, and alcohol use in past 30 days were significantly associated with unprotected sex. Lifetime history of nonheroin opiate use and HAART use each demonstrated an inverse association with unprotected sex (Table 3).
We found that 8.9% of overall participants reported sharing needles in the previous 90 days (Table 2). In the bivariate analyses, sexual orientation; homelessness; past 30-day heroin, cocaine, amphetamine, and marijuana use; lifetime alcohol and amphetamine use; Addiction Severity Index-Lite alcohol and drug scores; HIV symptom distress score; Brief Symptom Inventory anxiety score; and Center for Epidemiologic Studies Depression Scale score were significantly associated with needle sharing at the P < 0.1 level (data not shown). Factors in the bivariate analysis that were inversely related to needle-sharing at the P < 0.1 level were: SF-12 general health, social functioning, role emotional, and mental health scores, and current HAART use. In the parsimonious multivariate analysis, factors associated with needle-sharing were: past 30-day amphetamine use, past 30-day amphetamine use, homelessness, and BSI anxiety score (Table 4).
Our findings provide a cross-sectional view of treatment-seeking HIV-infected opioid-dependent patients across the United States, encompassing diverse geographic and clinical settings as well as a range of treatment models. We identified several key findings in patient characteristics that will generate additional research directions and may help guide program development. In terms of substance use, over half of these opioid-dependent individuals reported using cocaine in the previous month, and approximately half reported alcohol consumption in the previous month. We also found that a substantial portion of study participants engaged in recent HIV transmission risk behaviors. This is salient because in general, these participants were engaged in HIV care, suggesting that attention to transmission risk behaviors is an area that needs continual attention from HIV care providers, addiction treatment providers, and researchers.
Our data suggest that among these opioid-dependent individuals, other substance use, principally cocaine and alcohol, is common. Cocaine use in our study population is discussed in detail elsewhere in this supplement.43 Alcohol use among persons with HIV is associated with poorer adherence,44,45 lower rates of viral suppression21,25,26 and HIV progression.26 Among those who use illicit drugs, studies suggest that those using stimulants, including cocaine and crack, may be least likely to access care46,47 and when in care tend to have poorer adherence to treatment.18,20
These data highlight the need for comprehensive assessment and treatment for other substances in addition to opioids, including alcohol, which almost half of participants reported using in the past month. This is an important issue for office-based treatment programs that might not have resources available on-site for managing other substance use. Facilitated linkage and referral to other treatment services may be important in addressing multisubstance use. Still, effective behavioral and pharmacologic therapies for risky alcohol use exist, and the evidence has shown that brief interventions in healthcare settings can help decrease alcohol consumption in some patients not seeking alcohol treatment.48 One study found that a low-cost HIV primary care alcohol intervention was effective and could be sustained.49
Almost one fourth of those having sex reported having had anal or vaginal sex without a condom in the previous 90 days; 8.9% of overall participants reported sharing needles in the previous 90 days. A recent CDC study of data from the National HIV Behavioral Surveillance System50 found that in the prior 12 months: 32.8% of persons reporting IDU shared needles or syringes and 58.5% shared other injection-related equipment (such as “cookers” or rinse water); 63.4% engaged in unprotected vaginal intercourse and 47.8% reported multiple sex partners. In the same CDC study, 66.3% of IDUs were tested for HIV during the prior 12 months and 72.2% reported ever having been tested for or having a diagnosis of hepatitis C virus.50 Thus, the majority of these active drug users are interfacing with the health system, which affords an opportunity for risk reduction intervention. Our study participants had lower but still substantial rates of unprotected sex and needle-sharing. The reasons for this difference are not known but may reflect increased HIV transmission knowledge, fear of HIV transmission, or engagement in care for HIV or for substance abuse. Almost half of our participants had been in substance abuse treatment in the previous 90 days. Additionally, we did not limit our study to IDU.
Risk factors in our study for having unprotected sex included having a partner, female gender, and alcohol use in the previous 30 days. We did not collect data on the HIV serostatus of partners in this study. Further exploration of knowledge, attitudes, and behaviors of HIV-infected opioid-dependent women concerning condom use is warranted to understand the barriers to more regular condom use in the population. The relationship between substance use and sexual risk behaviors has been explored in many studies with mixed results. A number of studies have shown increased sexual risk behaviors associated with alcohol and drug use,51-55 whereas others have shown varied or negative results, particularly when the outcome of interest is condom use.56-61
In our study, HAART use had an inverse relationship with unprotected sex, suggesting that engagement in care may play a role in, or be a marker for, risk reduction. We also found that lifetime use of nonheroin opiates had an inverse relationship with unprotected sex.
Risk factors in our study for needle-sharing included other substance use, homelessness, and anxiety. Amphetamine use and marijuana use were each independently associated with needle-sharing. This again highlights the need for comprehensive treatment strategies that addresses mental health and substance use in addition to opioid use. Amphetamine use and marijuana use were the most strongly associated with needle-sharing; those who used amphetamines were almost five times as likely to share needles as those who did not. Amphetamine-type stimulants such as methamphetamine have been associated with sexual risk behaviors,62 but our study suggests that needle-sharing is also an important consideration among those who use Amphetamine-type stimulants. There is very little known about the relationship between cannabis and HIV transmission risk behaviors, but our study suggests that further exploration of this is warranted.
Our study also suggests that addressing mental health may play a role in reducing HIV transmission risk. In a prior study, Lyketsos et al studied patients entering into HIV care at one of our sites (Baltimore, MD) and found that 40% had a primary psychiatric diagnosis plus current or prior substance use disorder.63 Mental health has been identified as an important cofactor in adherence to HIV treatment.17,64 Other studies have demonstrated that having psychiatric disorder may be associated with virologic failure65 and AIDS-related mortality66 and that engagement in mental health services has been associated with increased survival.66 Thus, concomitant identification and management of both substance-related and primary psychiatric diagnoses is essential in this population with a high prevalence of co-occurring disorders and should be further explored in studies of the impact of substance use disorders on HIV disease and secondary transmission of HIV.
Twenty-five percent of study participants were homeless; homeless individuals had over four times the odds of needle-sharing compared with adequately housed individuals. It has been estimated that 10% to 20% of homeless persons abuse drugs actively67,68 with a lifetime prevalence ranging from 25% to 50% according to some estimates.69 One survey in New Haven, CT, found that 25% of homeless people identified drug use as the primary reason for their being homeless.70 A study of CDC data on behavioral surveillance in HIV-infected persons at 19 sites found that self-reported physical and mental health was worse among homeless persons and that homeless persons had lower CD4 counts, were less likely to have used HAART, and were less adherent to HAART.71 Homelessness also has been demonstrated to increase the risk for transactional sex and other risky sexual behavior.72-74
Limitations to this study include reliance on self-reported data collection. The use of audio computer-assisted interview at some sites helps ameliorate this issue, although some social desirability bias and recall bias is likely present. Second, we cannot make direct comparisons among treatment groups, because there was no uniform system of treatment assignment across sites, and participants were not randomized to treatment groups. Additionally, our analysis of risk behaviors was cross-sectional, limiting our ability to make causal inferences about relationships between factors and relationships. Finally, the study designs were heterogeneous across sites. This may be a limitation in terms of internal validity and interpretation of our analysis of risk behaviors; however, it may also be considered a strength of our study in terms of generalizability to real-world clinical situations.
Our demonstration program characterizing a diverse population of opioid-dependent, HIV-infected persons entering treatment at sites across the country is the first of its kind evaluating the impact of integrated bup/nx and HIV care on a wide range of health outcomes. This particular study offers insights into the characteristics and particular needs of this population. Our study demonstrates that addressing HIV risk behaviors among HIV-infected persons entering opioid agonist treatment is an important secondary HIV prevention strategy. Furthermore, in addition to treatment for opioid dependence, addressing other substance use, social issues-particularly stable housing-and mental health is critical in efforts to reduce HIV risk behaviors and may have important implications for reducing HIV transmission.
The BHIVES Collaborative, sites, and Principal Investigators: R. Finkelstein and D. Fiellin, K. Carmichael, D. Sylvestre, P. T. Korthuis, C. Cunningham, M. Fischl, University T. Flanigan, P. Lum, G. Lucas, J. Watts, R. Altice, L. Sullivan, and M. N. Gourevitch, (Chair, National Advisory Committee). For more information, go to HYPERLINK “http://www.bhives.org” www.bhives.org.
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