Newton et al. found that positive reinforcement through pleasureseeking behaviors was the primary motivator for most METH+ individuals, however, pain avoidance was also an important, non-overlapping factor. Thus, people may engage in methamphetamine use and subsequent riskier sexual behaviors as coping methods to avoid the emotional pain associated with loneliness and/or rejection, particularly if they have poor inhibitory control. Torres and Gore-Felton proposed this type of paradigm, which they called the Loneliness and Sexual Risk Model , that posits that the relationship between loneliness and sexual risk behavior is mediated by substance use and impulsive behavior. In our sample, individuals who experienced potentially problematic levels of loneliness reported significantly higher impulsivity/disinhibition than those who reported loneliness within normal limits across both METH−/+ groups, providing initial support for the LSRM model. However, in separate multi-variable regression models with beliefs and intentions to practice safer sex as outcome variables, the interaction between potentially problematic loneliness and methamphetamine status was statistically significant while impulsivity/disinhibition was not, suggesting that an individual who is methamphetamine dependent and lonely has worse beliefs and intentions to practice safer sex than their lonely METH− counterparts, regardless of their impulsivity/disinhibition level. Polysubstance use is an important aspect in methamphetamine dependence that was also considered in our cohorts . Of the three nonmethamphetamine lifetime substance use disorders that were examined , there was a significant association between loneliness with lifetime opioid use disorder. This association was found in only the methamphetamine dependent group, but occurred in the opposite direction than what was to be expected. However, given the relatively low prevalence of positive lifetime opioid use disorder in the whole sample,grow glide rack as well as within the methamphetamine dependent group , these findings may have been driven by a skewed sample.
Even when DSM-IV substance use disorder criteria were not considered, the number of individuals reporting any lifetime opioid use was low , again suggesting a skewed, non-representative sample of opioid users. By contrast, alcohol and cannabis were the substances that had the most number of people reporting any lifetime use . Post-hoc analyses found that both cumulative densities of alcohol and cannabis were significantly higher in the METH+ than the METH− group, suggesting that methamphetamine dependent individuals consumed larger quantities of these substances over shorter periods of time relative to individuals who were not methamphetamine dependent. However, neither alcohol density or cannabis density predicted loneliness, beliefs about practicing safer sex, or intentions to practice safer sex. Rather, methamphetamine dependence consistently predicted these variables above and beyond alcohol use, cannabis use, and other covariates such as age and HIV status, indicating its robust effects on both loneliness and the potential of engaging in riskier sexual behaviors. Our study did not find a link between poorer norms and intentions to practice safer sex among people with HIV who had undetectable viral loads, suggesting that they are equally as concerned about taking part in unsafe sex compared to people with HIV who were detectable for the virus. However, people with HIV are more likely to engage in riskier sexual behaviors in the past 6 months and prior to the past 6 months than HIV− individuals. We did not find an association between loneliness and self-reported, past sexual risk behaviors in the whole sample. However, given the cross-sectional nature of our study, it may be inappropriate to link current feelings of loneliness with past risky sexual behaviors. Rather, it may be more informative to investigate the factors that have been shown to be significantly associated with future sexual risk behaviors in the literature such as attitudes, personal norms, and intentions of engaging in safer sex . Indeed, our data confirmed that beliefs and intentions of engaging in safer sex were significantly associated with lower current sexual risk. Findings from this study have potential, important public health implications related to identifying and treating individuals who may be at-risk for engaging in HIV-transmission risk behaviors. Prior work has shown that methamphetamine use is a predictor of riskier sexual intentions and riskier sexual practices . However, changing drug use behavior may not be a realistic goal, or sufficient target in sexual risk reduction interventions; rather, addressing maladaptive coping due to emotional distress may be more successful .
Thus, identification of lonely individuals who are dependent on methamphetamine, and whom we found were more likely to report poorer personal norms and intentions to engage in safer sex practices, allows us to capture an at-risk group and consider alternative approaches that could be integrated into substance use treatment programs to reduce riskier sexual behaviors. Increased opportunities for social contact , one-on-one or group interventions based on mutual aid, enhanced social support , improving social skills , and addressing maladaptive social cognitions may all be important target areas to reduce the prevalence of loneliness in this at-risk population. Though this study provides preliminary evidence for the importance of identifying those with high feelings of loneliness, and its implications on future attitudes and beliefs about engaging in potentially risky behaviors, it is not without limitations. First, our data are cross-sectional, so we cannot assume directionality or claim that loneliness influences riskier personal norms and intentions to practice safer sex. It is entirely possible that a bidirectional relationship may exist. Our selection criteria were developed such that they focused on studying methamphetamine effects while minimizing the potential confounding effects of other substances. By doing so, generalizability of findings to poly-substance users becomes more limited. Similarly, recruitment from HIV clinics may introduce some confounding factors that may not have been fully accounted for by controlling for HIV status, thus potentially limiting generalizability to non-HIV populations. Though results from our recruited sample suggest that the relationship between loneliness and riskier beliefs and intentions about practicing safer sex are theoretically relevant to many kinds of individuals , future work should specifically examine whether there are particularly risky periods of methamphetamine addiction in which loneliness more strongly influences riskier beliefs and intentions about safer sex practices, which could be investigated by evaluating the specific recruitment sources . Furthermore, given the discrepancy between average age of first methamphetamine use relative to the average age in the METH+ sample , a potential survival bias may exist, which may skew findings. Of note, the proportion of individuals with HIV in the METH− and METH+ groups were nearly identical , suggesting that if survival bias is present, it is more likely specific to methamphetamine-related characteristics rather than HIV-related selective survival bias. Our current design also did not query further into the dimensions of loneliness that an individual may be encountering . Additionally, although our sample was large enough to see robust effects, it was relatively small, especially considering the number of potentially important covariates.
This research would ideally be replicated in a larger sample of METH− and METH+ individuals. Further work should also investigate how loneliness may differentially influence attitudes about sex among individuals with different partner statuses , as well as among sexual and gender minorities,grow rack greenhouse especially given important considerations raised by Bryant et al. and Race et al. regarding the role of controlled drug use and safer sex in facilitating community, building identity, and responding to marginalization in such minority groups. Despite these limitations, our findings highlight the high prevalence of loneliness among individuals with methamphetamine use disorder, and explores the potential impact of loneliness among those who are typically at-risk of engaging in HIV-related risk behaviors by finding a unique association between loneliness and riskier beliefs and intentions regarding the practice safer sex. These results suggest potential areas of intervention, including promotion of adaptive beliefs and intentions to engage in safer behaviors. In addition, findings from this study are highly relevant during the current COVID-19 pandemic, as individuals have been required to engage in unprecedented social distancing and may be experiencing the effects of prolonged social isolation. Consequently, feelings of loneliness and mental health problems could be elevated , and may contribute to engagement in riskier behaviors such as practicing poorer safer sex in order to feel social connection, pleasure, and avoid emotional pain. In an era when antiretroviral therapy is recommended for all people living with HIV regardless of CD4+ T-cell count, best clinical practices and high-impact interventions emphasize retention in care and ART adherence. Achieving and maintaining viral suppression is crucial to optimizing health outcomes and substantially reducing the risk of onward HIV transmission. At the same time, consistent evidence indicates that economic disparity is a driving force of the HIV epidemic and undermines these efforts in regions throughout the world, including Africa, Asia, Europe and North America. Poverty is a major barrier to receiving care and achieving success at each step of the HIV care continuum for PLWH in countries across the spectrum of income and resource availability. Even in well-resourced settings, in which infrastructure exists to provide facilities, clinicians, laboratory, and supply chain management for various types of health care, a number of factors associated with poverty act as barriers to care. Recognition of such barriers has led to specific models for understanding health services use, including the Behavioral Model for Vulnerable Populations. This model posits that, in addition to factors limiting health services use in the general population, such as age, income and health insurance, there are factors uniquely common in vulnerable populations that act as additional barriers to care, including violence, incarceration, substance use and homelessness.
Homelessness can result from a variety of conditions and co-occurring predictors that are often associated with poverty, and it stands out as a strong predictor of poor HIV outcomes. In Canadian and U.S. cities, where resources exist to provide HIV care for low-income individuals, homelessness predicts a failure to use ART, housing eviction predicts unsuppressed viral load, and becoming housed predicts viral suppression. International guidelines for improving ART adherence recognize housing instability as a barrier to adherence and provide recommendations for homeless individuals that emphasize the need for retention in care as well as case management. The degree to which recent care and case management influence viral suppression among low-income and homeless persons is unclear. Their influences are particularly uncertain when considered alongside factors known to predict VL in low-income individuals, such as food insecurity, substance use and inconsistent health insurance. Similarly, their influences are uncertain among low-income women living with HIV , in whom substance use and violence are both disproportionately common and act synergistically to negatively influence health outcomes, particularly in the context of urban poverty. Issues of poverty and homelessness are important because homelessness is increasing around the world, including in resource-rich areas across Europe and North America. In fact, civil emergencies due to homelessness have been increasing in U.S. cities, and clinics caring for PLWH in resource-rich areas report that the degree of housing instability affects population-level rates of viral suppression. However, factors unique to the health of homeless and unstably housed persons are still routinely overlooked. In addition, while homeless women have different –often more severe –needs and patterns of morbidity and mortality compared to men, women are often under-sampled in homeless research, including HIV-specific homeless research. Moreover, while prior research points to any homelessness as a risk factor for negative health outcomes, data on exposure levels of various housing conditions, such as the number of nights spent sleeping in a given venue, and its impact on virologic outcomes among women, are lacking. We conducted one of the first longitudinal studies to determine independent associations between factors uniquely common in low-income women living in a well-resourced urban environment and unsuppressed viral load, with an emphasis on housing and SAVA syndemic factors. Prior research in this population suggests that different types of living conditions beyond “homeless,” including various types of homelessness and residence in low-income single room occupancy hotels, contribute to health status, but the impact of these factors on viral load has not previously been assessed. Informed by the Behavioral Model for Vulnerable Populations, we hypothesized that multiple types of living conditions would be associated with unsuppressed VL. Our goal was to inform programs and interventions aimed at decreasing detectable viremia in low-income WLWH. Participants provided written informed consent for all study activities, including medical record review. Reimbursement of $15 was given for each study interview and $5 per month was given to update contact information.