Separate multinomial logistic regression models were performed for each sexual risk behavior: unprotected sexual intercourse with regular partners, unprotected sexual intercourse with casual partners, number of sex partners, having at least one high risk sex partner, and engaging in sex under the influence. We calculated changes in both ASI alcohol and drug composite scores and entered them in each regression model simultaneously as independent variables. Age, ethnicity, treatment modality, intervention condition, and number of intervention sessions attended were entered into the regression models as covariates.In the current study, we found high rates of ongoing sexual risk behaviors, with more than half of the sample reporting unprotected sex or having sex under the influence of drugs and/or alcohol, and a considerable minority reporting multiple sex partners and high risk sex partners. Most sexual risk behaviors decreased in frequency during the course of the study. We found relationships between decreased sexual risk behaviors and decreased drug/alcohol use severity, which were independent of treatment modality and intervention assignment modality. Overall, drug and alcohol use severity declined and most sexual transmission risk behaviors declined during the six month period. Rates of unprotected sex with both regular and casual partners decreased during the six month time frame of the study. However, these changes were not associated with changes in drug or alcohol severity. The HIV risk reduction interventions received may have driven the decrease in unprotected sex. As SUD treatment outcomes were not associated with changes in unprotected sex, this behavior likely requires specific intervention. Available interventions to decrease rates of unprotected sex have proven effective. REMAS significantly increased the percentage of protected sexual occasions compared to a control condition .
Other system-level interventions,rolling tables grow such as having free condoms available, can decrease rates of unprotected sex . Our findings demonstrate that the relationship between alcohol use severity and multiple sex partners can change over time, consistent with previous findings . Here, alcohol treatment might serve as a method of decreasing the behavior, resulting in a decrease in the incidence of HIV. Increases in drug use severity coincided with the initiation of a sexual relationship with a high risk partner, while the maintenance of a relationship with a high risk partner was associated with decreased drug use severity. This reduction is possibly the result of the interventions administered to participants during the course of the study. Meanwhile, the initiation of a relationship with a high risk sex partner may suggest a worsening of the individual’s substance use treatment outcomes. Also, discontinuing sex with a high risk partner was not associated with any change in drug use severity. Sex under the influence of alcohol and/or drugs decreased over the measured six months of drug treatment. Further, decreases in sex under the influence were associated with decreases in drug use severity. Drinking before a sexual encounter has been linked to sex with a high risk partner . This has been theorized to be associated with the disinhibition of alcohol, which leads users to perceive less risk and have more positive outcome expectations , and some evidence indicates it may be the case in stimulant users as well . The percentage of individuals who reported at least one high risk sex partner, however, remained unchanged during the course of the study. It may be difficult for participants in substance use treatment, whose peers are also substance users, to find low risk partners. Addressing one risk factor may decrease other risk factors as well. Sex under the influence is frequent and associated with other sex-risk behaviors, such as sex with casual partners and unprotected sex .
Having a high risk partner has previously been associated with increased condom use . As such, it is possible that decreasing drug use severity can impact several sex-risk behaviors through the vector of sex under the influence. The study’s results have implications for SUD treatment programs. Specifically, counselors in methadone maintenance treatment and outpatient drug-free programs should discuss the risk status of their clients’ sexual partners. This can be coupled with a discussion about condom use, including hands-on demonstrations on how to apply condoms. Also, incorporating cognitive-behavioral therapy and motivational interviewing can decrease sexual risk behaviors and substance use, while also helping to increase knowledge and skills that can lead to safer sex . Interventions should address the isolation and vulnerability that can lead individuals into risky sexual encounters . This study has limitations that suggest the need for further research. First, all participants enrolled in this study to participate in HIV risk reduction interventions, suggesting greater readiness to change than expected among all SUD treatment participants. As a result, findings may not be generalizable to SUD treatment patients less concerned about HIV transmission. It is important to note that participants in this study were not tested for HIV nor was information regarding participants’ HIV status gathered in the current study. Individuals may differ in their risk behavior based on their HIV status, as positive individuals may change their previous behaviors . Sexual dysfunction can result from methadone and chronic alcohol use , which could have influenced our results. We also do not have information on why certain participants are no longer in treatment , which could confound our data. Analyzing the data categorically obscures and fails to reveal the actual magnitudes of changes. Also, we calculated change scores for substance use severity, which are controversial among researchers .
Our study highlights the importance of drug and alcohol treatment in the reduction of sex risk behaviors. As the sexual transmission of HIV continues to increase , more understanding of this phenomenon is needed. Drug and alcohol use severity are associated with these risk behaviors, and treating the substance use in drug treatment may reduce HIV risk behaviors. However, some risk behaviors remain unchanged in spite of changes in drug and alcohol use severity, and require specific interventions. Further research is needed to pinpoint the effect of drug treatment independent of other factors, including having sex for money or drugs. Also, participants of different treatment modalities may have different risk patterns, and may respond differently to interventions. Drug treatment provides the opportunity for specialized HIV risk behavior interventions, which should be expanded upon wherever possible. Despite viral suppression on combination antiretroviral therapy , people with HIV suffer from depressed mood and chronic inflammation. Depression is the most common psychiatric comorbidity in HIV . Depressed PWH show poorer medication adherence , lower rates of viral suppression , greater polypharmacy , poorer quality of life and shorter survival . A subtype of treatment-resistant depression in the general population is associated with chronic inflammation . The potential clinical significance of this is high, since the anti-inflammatory TNF-alpha blocker tocilizumab and other drugs such as the antibiotic minocycline, the interleukin 17 receptor antibody, brodalumab, and the monoclonal antibody, sirukumab, have been shown to be effective treatment for this depression subtype , but these have not been studied in the context of HIV. Inflammation is associated with greater symptom severity, differential response to treatment, and greater odds of hospitalization in patients with major depressive disorder . Chronic inflammation persists in virally suppressed PWH and predicts morbidity and mortality . There also is an extensive literature on showing that depression correlates with markers of inflammation and immune activation in PWH , but most of these studies were performed in individuals who were not virally suppressed. We hypothesized that inflammation in virally suppressed PWH would be associated with poorer mood.We found that higher concentrations of a specific panel of markers of inflammation in blood were seen in PWH with worse depression. Additionally, PWH with depressed mood had markedly reduced quality of life and were more dependent in IADLs. In addition, higher inflammation associated with worse scores on numerous life quality indicators. Chronic HIV-associated inflammation and immune dysfunction have emerged as key factors that are strongly linked to nonAIDS complications . Our findings confirm those of previous investigations , and extend them by evaluating a more comprehensive panel of biomarkers and more extensive evaluation of impact on daily functioning and quality of life. If the link between inflammation and depression is causal,4×8 botanicare tray our results suggest that treatment with selected anti-inflammatory medications might benefit mood and life quality in some PWH. Depressed mood was specifically associated with a factor loading on d-dimer, IL-6 and CRP. Factor analysis is a statistical method used to describe variability among observed, correlated variables in terms of a potentially lower number of unobserved variables called factors. Thus,factor analysis is a method for dimensionality reduction and can help control false discovery.
Additionally, however, it is important to check the identified factors against known physiological relationships. Several prior reports link these specific markers with each other, particularly in the context of HIV, suggesting that they represent a physiologically congruent aspect of the inflammatory cascade. For example, the proinflammatory cytokine IL-6 stimulates the production of C-reactive protein in the liver . In one study, higher pre-ART CRP, D-dimer, and IL-6 levels were associated with new AIDS events or death . Also, in HIV patients, IL-6, hsCRP and D-dimer were intercorrelated and each was associated with an increased risk of cardiovascular disease independent of other CVD risk factors . In another report, baseline IL-6 and D-dimer were strong predictors of coronary risk in non-HIV-infected individuals and were associated with each other and with CRP . Additional support for the coherence of Factor 2 is that its components in this dataset demonstrate robust and statistically significant intercorrelations, while their correlations with other biomarkers are typically weaker and not statistically significant . Previous studies have demonstrated the importance for depression of the specific biomarkers identified in Factor 2. BDI-II scores at baseline and follow-up were highly correlated. Together with the finding that higher inflammatory markers at 12-year follow-up also were associated with depressed mood at baseline, these findings suggest that depressed mood is an enduring phenotype. A novel finding in this study was that although women had worse depressive symptoms, the association with inflammatory markers was seen only in men. While perhaps reflecting limited power due to the small number of women, this suggests that the underlying pathophysiology of depression is different in men and women with HIV. Of note, women tended to have higher markers of inflammation than men, consistent with a previous report . We found worse depression in non-Hispanic whites than in other ethnicities. This is consonant with higher rates of depressive disorders in whites in previous studies . The relationship between inflammation and depressive mood remained after accounting for ethnicity. Inflammation was not related to CD4 or viral load in this cohort of mostly virally suppressed PWH. Unlike other studies, elevations in inflammatory biomarkers were not associated with substance use disorders. Higher inflammatory biomarkers also were associated with greater disability , motor impairment, poor physical health , poorer general health, physical function, role function, social function, pain function, and worse health distress, emphasizing the importance of this phenotype. Inferences are limited by several factors in this study. There were relatively few women, However, inspection of the scatterplot reveals that there was no suggestion of a trend for an association between inflammation and depression in women. The panel of soluble biomarkers studied was limited, and important associations may have been missed. We did not characterize cellular markers of inflammation in these participants. The absence of a control group precludes consideration of whether effects of inflammation on depression are mediated or otherwise influenced by HIV infection itself. As noted previously, anti-inflammatory medications have shown promise for treatment-resistance depression. Future studies might evaluate the effectiveness of anti-inflammatory medications for the treatment of depression in PWH selected for the presence of inflammation and treatment resistance.North America comprises the world’s largest drug market and evidences the highest drug related mortality rate in the world , 2011. Within the United States the problem of prescription drug misuse and opioid misuse in particular, has reached epidemic proportions. Pain relievers were the most commonly misused drug in the psychotherapeutics category from 2002 to 2011 , 2012 and from 2004 to 2011, the number of medical emergencies involving opioids increased by 183% . Abuse of prescription drugs is a significant public health problem, associated with high costs both to the health care system and to the individuals who use them. From an economic perspective, it is estimated that opioid misusers’ medical care costs are eight times greater than those of non-misusers .