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Center on Stress and Health

Health Risk Behavior

Remien, R. H., T. M. Exner, S. F. Morin, A. A. Ehrhardt, M. O. Johnson, J. Correale, S. Marhefka, S. B. Kirshenbaum, L. S. Weinhardt, M. J. Rotheram-Borus, S. L. Catz, C. Gore-Felton, M. A. Chesney and J. Kelly (2007). "Medication adherence and sexual risk behavior among HIV-infected adults: implications for transmission of resistant virus." AIDS Behav 11(5): 663-75.
As more people are living long-term with HIV there are growing concerns about specific behaviors that can affect both personal and the public health. This study examined the relationship between antiretroviral therapy (ART) adherence and sexual risk behavior and their association with psychosocial and health factors among a diverse sample of 2,849 HIV-infected adults. Only 8.5% of the sample reported both non-adherence and sexual risk. Individuals were 46% more likely to report one of these risk outcomes when the other one was present and the presence of both outcomes was associated with an increased likelihood of having a detectable viral load. A simultaneous polytomous regression analysis revealed complex relationships among a range of psychosocial variables and the two primary behavioral risk outcomes. There is a need for targeted interventions and integration of mental health and substance use services into primary HIV care settings.

Hong, D. S., R. B. Goldstein, M. J. Rotheram-Borus, F. L. Wong and C. Gore-Felton (2006). "Perceived partner serostatus, attribution of responsibility for prevention of HIV transmission, and sexual risk behavior with "MAIN" partner among adults living with HIV." AIDS Educ Prev 18(2): 150-62.
Persons living with HIV (PLH) often attribute HIV status to sexual partners based on observable partner characteristics. The present study investigated the relationship of sexual behavior with most recent "main" partner to that partner's perceived serostatus among 1,232 PLH interviewed in clinics and community agencies in Los Angeles, California. PLH who believed their most recent main partner to be HIV-negative more often identified partner appearance as a basis for their perceptions than those who believed their most recent main partner to be HIV-positive. PLH who perceived their most recent main partner as HIV-negative were more likely to assume responsibility for partner protection and always to use condoms, and less likely to report recent unprotected vaginal or anal sex with that partner. Unprotected receptive anal intercourse with their most recent main partner was less common among African American, Latino, and White participants who believed that partner to be HIV-negative. Although PLH appear protective toward HIV-negative main partners, interventions to encourage valid methods of identifying partner serostatus are needed.

Sikkema, K. J., E. S. Anderson, J. A. Kelly, R. A. Winett, C. Gore-Felton, R. A. Roffman, T. G. Heckman, K. Graves, R. G. Hoffmann and M. J. Brondino (2005). "Outcomes of a randomized, controlled community-level HIV prevention intervention for adolescents in low-income housing developments." Aids 19(14): 1509-16.
OBJECTIVES: Youth are increasingly at risk for contracting HIV infection, and community-level interventions are needed to reduce behavioral risk. DESIGN: A randomized, controlled, multi-site community-level intervention trial was undertaken with adolescents living in 15 low-income housing developments in five US cities. METHODS: Baseline (n = 1172), short-term follow-up (n = 865), and long-term follow-up (n = 763) risk assessments were conducted among adolescents, ages 12-17, in all 15 housing developments. The developments were randomly assigned in equal numbers to each of three conditions: experimental community-level intervention (five developments); "state-of-the-science" skills training workshops (five developments); and, education-only delayed control intervention (five developments). RESULTS: At long-term follow-up, adolescents living in the housing developments receiving the community-level intervention were more likely to delay onset of first intercourse (85%) than those in the control developments (76%), while those in the workshop developments (78%) did not differ from control condition adolescents. Adolescents in both the community-level intervention (77%) and workshop (76%) developments were more likely to use a condom at last intercourse than those in control (62%) developments. CONCLUSIONS: Community-level interventions that include skills training and engage adolescents in neighborhood-based HIV prevention activities can produce and maintain reductions in sexual risk behavior, including delaying sexual debut and increasing condom use.

Ksobiech, K., A. M. Somlai, J. A. Kelly, C. Gore-Felton, E. Benotsch, T. McAuliffe, K. Hackl, D. Ostrovski and A. P. Kozlov (2005). "Demographic characteristics, treatment history, drug risk behaviors, and condom use attitudes for U.S. and Russian injection drug users: the need for targeted sexual risk behavior interventions." AIDS Behav 9(1): 111-20.
Two separate databases, one on Russian (n = 444) injection drug users (IDUs), and the other on U.S. IDUs (n = 241), were merged, and responses were compared. Results indicated that Russian IDUs perceived themselves to be at greater risk for HIV/AIDS based upon behaviors over the past 90 days. U.S. IDUs were more likely to be tested for HIV, report a negative HIV result, and know more people with HIV. U.S. IDUs consumed greater amounts of alcohol and marijuana, and made more alcohol/drug treatment attempts than Russian IDUs. Russian IDUs injected more frequently, although were more likely to recently use clean needles. Russian and U.S. IDUs responded significantly differently to eight AIDS knowledge questions. Eight condom attitude questions were asked of each group, and each revealed significantly different responses. Gender differences for Russian IDUs were also observed. There is a clear need to create culturally targeted sexual risk reduction interventions.

Gore-Felton, C., M. J. Rotheram-Borus, L. S. Weinhardt, J. A. Kelly, M. Lightfoot, S. B. Kirshenbaum, M. O. Johnson, M. A. Chesney, S. L. Catz, A. A. Ehrhardt, R. H. Remien and S. F. Morin (2005). "The Healthy Living Project: an individually tailored, multidimensional intervention for HIV-infected persons." AIDS Educ Prev 17(1 Suppl A): 21-39.
The NIMH Healthy Living Project (HLP), a randomized behavioral intervention trial for people living with HIV, enrolled 943 individuals, including women, heterosexual men, injection drug users, and men who have sex with men from Los Angeles, Milwaukee, New York, and San Francisco. The intervention, which is based on qualitative formative research and Ewart's Social Action Theory, addresses three interrelated aspects of living with HIV: stress and coping, transmission risk behavior, and medication adherence. Fifteen 90-minute structured sessions, divided into 3 modules of five sessions each, are delivered to individuals. Sessions are tailored to individuals within a structure that uses role-plays, problem solving, and goal setting techniques. A 'Life Project'--or overarching goal related to personal striving-provides continuity throughout sessions. Because this is an ongoing project with efficacy yet to be established, we do not report intervention outcomes. However, the intervention was designed to be useful for prevention case management, settings where repeated one-on-one contact is possible, and where a structured but highly individualized intervention approach is desired.

Winningham, A., S. Corwin, C. Moore, D. Richter, R. Sargent and C. Gore-Felton (2004). "The changing age of HIV: sexual risk among older African American women living in rural communities." Prev Med 39(4): 809-14.
BACKGROUND: African American women aged 50 and older are disproportionately affected by the HIV/AIDS epidemic. Despite African Americans making up 11% of all older women in the United States, in 2001, they accounted for more than 50% of AIDS cases among older women and more than 65% of HIV cases among older women. Using the AIDS Risk Reduction Model as a conceptual framework, this study investigated HIV risk behavior among older rural African American women (mean age = 58 years). METHODS: A cross-sectional survey was conducted (n = 181) in three rural counties in South Carolina. RESULTS: Most (67%) of the women had at least one sex partner in the past five years, and of these, more than half (59.5%) reported at least one sexual risk behavior. High-risk behavior was associated with less education, lower condom use self-efficacy, more peers who discussed HIV-related risk behavior, and less comfort communicating with partners about sex. CONCLUSIONS: A significant proportion of older African American women living in rural counties are at increased risk for HIV infection, suggesting an urgent need for HIV prevention efforts to target this population.

Weinhardt, L. S., J. A. Kelly, M. J. Brondino, M. J. Rotheram-Borus, S. B. Kirshenbaum, M. A. Chesney, R. H. Remien, S. F. Morin, M. Lightfoot, A. A. Ehrhardt, M. O. Johnson, S. L. Catz, S. D. Pinkerton, E. G. Benotsch, D. Hong and C. Gore-Felton (2004). "HIV transmission risk behavior among men and women living with HIV in 4 cities in the United States." J Acquir Immune Defic Syndr 36(5): 1057-66.
Determining rates of HIV transmission risk behavior among HIV-positive individuals is a public health priority, especially as infected persons live longer because of improved medical treatments. Few studies have assessed the potential for transmission to the partners of HIV-positive persons who engage in high-risk activities. A total of 3723 HIV-infected persons (1918 men who have sex with men [MSM], 978 women, and 827 heterosexual men) were interviewed in clinics and community-based agencies in Los Angeles, Milwaukee, New York City, and San Francisco from June 2000 to January 2002 regarding sexual and drug use behaviors that confer risk for transmitting HIV. Less than one quarter of women and heterosexual men had 2 or more sexual partners, whereas 59% of MSM reported having multiple partners. Most unprotected vaginal and anal sexual activity took place in the context of relationships with other HIV-positive individuals. Approximately 19% of women, 15.6% of MSM, and 13.1% of heterosexual men engaged in unprotected vaginal or anal intercourse with partners who were HIV-negative or whose serostatus was unknown. The majority of sexually active participants disclosed their serostatus to all partners with whom they engaged in unprotected intercourse. An estimated 30.4 new infections (79.7% as a result of sexual interactions with MSM) would be expected among the sex partners of study participants during the 3-month reporting period. Eighteen percent of 304 participants who injected drugs in the past 3 months reported lending their used injection equipment to others. In addition to the more traditional approaches of HIV test counseling and of focusing on persons not infected, intensive prevention programs for persons with HIV infection are needed to stem the future spread of the virus.

Sikkema, K. J., M. J. Brondino, E. S. Anderson, C. Gore-Felton, J. A. Kelly, R. A. Winett, T. G. Heckman and R. A. Roffman (2004). "HIV risk behavior among ethnically diverse adolescents living in low-income housing developments." J Adolesc Health 35(2): 141-50.
PURPOSE: To describe patterns and predictors of HIV risk behaviors among ethnically diverse, low-income adolescents. METHODS: Computer-assisted surveys were administered to 1172 adolescents between the ages of 12 and 17 years living in 15 low-income housing developments in three urban areas in the United States to characterize and identify predictors of HIV risk behavior. Data were analyzed using multinomial logistic regression to identify variables predictive of "no risk," "lower risk," and "higher risk" group classification. RESULTS: Most adolescents were not yet sexually active; nonetheless, a subset of youth reported high rates of HIV risk-related behaviors. HIV risk was highest among adolescents who were older, had weaker intentions to reduce risk, stronger beliefs that their sexual partners did not favor risk-reduction, lower risk-reduction behavioral skills, higher risk-reduction outcome expectation, and higher rates of substance use. CONCLUSIONS: HIV prevention efforts are needed that are tailored to ethnically diverse communities of adolescents, including those in early adolescence and those at highest risk.

Kalichman, S. C., C. Gore-Felton, E. Benotsch, M. Cage and D. Rompa (2004). "Trauma symptoms, sexual behaviors, and substance abuse: correlates of childhood sexual abuse and HIV risks among men who have sex with men." J Child Sex Abus 13(1): 1-15.
Childhood sexual abuse is associated with high-risk sexual behavior in men who have sex with men. This study examined psychological and behavioral correlates of HIV risk behavior associated with childhood sexual abuse in a sample of men who have sex with men. Men attending a large gay pride event (N = 647) completed anonymous surveys that assessed demographic characteristics, childhood sexual abuse history, symptoms of dissociation and trauma-related anxiety, borderline personality characteristics, substance use, and sexual risk behavior. Results indicated that men who have a history of childhood sexual abuse were more likely to: engage in high-risk sexual behavior (i.e., unprotected receptive anal intercourse), trade sex for money or drugs, report being HIV positive, and experience non-sexual relationship violence. Results of this study extend previous research to show that men who have sex with men and who have a history of child sexual abuse are more likely to be at high risk for HIV infection.

Gore-Felton, C., A. M. Somlai, E. G. Benotsch, J. A. Kelly, D. Ostrovski and A. Kozlov (2003). "The influence of gender on factors associated with HIV transmission risk among young Russian injection drug users." Am J Drug Alcohol Abuse 29(4): 881-94.
HIV infection rates are dramatically increasing in the Russian Federation. Epidemiological studies indicate that the greatest rise of HIV incidence has been among injection drug users (IDU). Young adults (N = 188) who reported injecting drug use completed surveys and interviews that assessed injection drug use behavior, sexual behavior, and HIV-related knowledge. The average age of participants was 21.3 years. Multiple linear regression analysis found male gender and younger age at sexual debut was positively and significantly associated with having multiple sexual partners. Gender moderated the effects of sexual debut and number of times injected drugs were used in the past month. Males who initiate sex at a younger age were more likely to report multiple sex partners and females who reported higher frequency of drug use were more likely to report multiple sex partners. Gender is an important factor, as well as moderator of risk behavior among Russian injection drug users. Delaying sexual debut, particularly for males, may be an effective strategy to reduce subsequent risk behavior. Prevention efforts among IDUs need to address sexual risk behavior in conjunction with injection risk behavior.

Somlai, A. M., J. A. Kelly, E. Benotsch, C. Gore-Felton, D. Ostrovski, T. McAuliffe and A. P. Kozlov (2002). "Characteristics and predictors of HIV risk behaviors among injection-drug-using men and women in St. Petersburg, Russia." AIDS Educ Prev 14(4): 295-305.
The purpose of this study was to establish the prevalence of high-risk sexual behaviors and drug-using behaviors in a large community sample of male and female injection drug users (IDUs) in St. Petersburg, Russia. This investigation used a data collection plan that systematically recruited a drug user sample from venues where IDUs were known to congregate and could be accessed. Surveys were completed by 239 IDUs (males = 139, females = 100), aged 13-25. Participants averaged 44 injections (range = 0-240) in the past 30 days, with heroin (70%) and heroin plus other drugs (20%) the most frequently used. Participants' mean age of first drug injecting was 17.6 years, 41% of participants regularly shared needles, most had multiple sexual partners (mean = 9.3 partners in the past 3 months), and 70% reported engaging in vaginal intercourse without condoms. Stepwise logistic regression showed that high-risk sexual behavior was predicted by being female, young, using heroin several times a month, and less negative attitudes toward using condoms. Effective HIV prevention efforts for IDUs in Russia must be tailored to their age, gender, drug use, and condom attitudes. These programs will also have to address the dual risk factors, unique to IDUs, of risky sexual behaviors and needle sharing. Without a rapid intervention response, Russia's HIV/AIDS crisis will soon turn catastrophic.

Rotheram-Borus, M. J., K. A. Mahler, C. Koopman and K. Langabeer (1996). "Sexual abuse history and associated multiple risk behavior in adolescent runaways." Am J Orthopsychiatry 66(3): 390-400.
Relationships between sexual abuse and sexual risk, substance use, emotional distress, and conduct problems were examined among 190 runaways. Those who had been abused were significantly more likely than nonabused peers to engage in unprotected sex, have more sexual partners, and use alcohol and drugs, but did not differ in emotional distress. Those abused after age 13 were more often engaged in sex work than nonabused peers. Males abused before age 13 had more sexual partners than those not abused, and runaway males were significantly more likely to have been sexually abused than has been reported in prior research.

Canterbury, R. J., E. L. McGarvey, A. E. Sheldon-Keller, D. Waite, P. Reams and C. Koopman (1995). "Prevalence of HIV-related risk behaviors and STDs among incarcerated adolescents." J Adolesc Health 17(3): 173-7.
PURPOSE: To determine the HIV-related risk behaviors and STDs in a population of incarcerated adolescents in order to strategically target education and prevention efforts. METHODS: A single point-in-time prevalence study based on an analysis of intake medical records of 1,215 incarcerated youth were analyzed for HIV risk behaviors and STD history. RESULTS: Incarcerated adolescents report high rates of risk behaviors for HIV infection and STDs, with 75% reporting three or more sex partners, 25% never using condoms and 19% having a current diagnosis of at least one STD. Significantly more females than males reported a history of STDs and had higher rates of current diagnoses of chlamydia/non-gonococcal urethritis, trichomonas and gonorrhea. CONCLUSIONS: Ethnic/racial and gender differences were found in risk behaviors for STDs among a sample of incarcerated adolescents.

Rotheram-Borus, M. J., C. Koopman, C. Haignere and M. Davies (1991). "Reducing HIV sexual risk behaviors among runaway adolescents." Jama 266(9): 1237-41.
OBJECTIVE. Reductions in runaways' sexual risk behaviors were evaluated in response to an intensive program to prevent human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS). DESIGN. In a nonrandomized control trial, sexual risk behaviors among 78 runaways at one residential shelter who received up to 30 HIV/AIDS intervention sessions were compared with 67 runaways at a nonintervention shelter with sexual behaviors assessed at baseline and 3 and 6 months. SETTING. Runaways were recruited from the only two publicly funded shelters in New York, NY. PARTICIPANTS. The runaways were aged 11 to 18 years, 64% female, and predominantly black or Hispanic. INTERVENTION. The intervention addressed general knowledge about HIV/AIDS, coping skills, access to health care and other resources, and individual barriers to safer sex. MAIN OUTCOME MEASURES. Consistent condom use, a high-risk pattern of sexual behavior, and sexual abstinence over a 3-month time frame were assessed. MAIN RESULTS. As the number of intervention sessions increased, runaways' reports of consistent condom use increased significantly (at 3 months, unique R2 = .06, P less than .05; at 6 months, unique R2 = .09, P less than .05), and their reports of engaging in a high-risk pattern of sexual behavior decreased significantly (at 3 months, unique R2 = .03, P = .06; at 6 months, unique R2 = .04, P less than .05). Abstinence did not change. CONCLUSIONS. The demonstrated effectiveness of the intensive HIV/AIDS program highlights the importance of enlarging the scope of most current HIV/AIDS prevention programs.

Rotheram-Borus, M. J. and C. Koopman (1991). "Sexual risk behavior, AIDS knowledge, and beliefs about AIDS among predominantly minority gay and bisexual male adolescents." AIDS Educ Prev 3(4): 305-12.
Current sexual risk behavior, AIDS knowledge, and beliefs about AIDS prevention were examined among 59 black and Hispanic male adolescents attending a community center for gay and lesbian youth. Most (73%) were sexually active in the last 3 months, with a median of 2.0 partners and with only 21% reporting consistent condom use. These youths demonstrated moderately high AIDS knowledge (82%) and positive beliefs endorsing AIDS prevention (71%). When risk pattern was defined on the basis of partners, risk acts, and condom use, positive AIDS prevention beliefs were significantly and inversely associated with the high-risk pattern, but not with abstinence. These results suggest that youths who frequently engage in high-risk acts need intervention targeting changes in beliefs and behavior, as well as knowledge.

Rotheram-Borus, M. J. and C. Koopman (1991). "Sexual risk behaviors, AIDS knowledge, and beliefs about AIDS among runaways." Am J Public Health 81(2): 208-10.
Sexual risk behaviors, knowledge of acquired immunodeficiency syndrome (AIDS), and beliefs about AIDS prevention were examined among 126 runaways. In the previous 3 months, 65 percent of youths had been sexually active. Among the sexually active runaways, males reported a median of 2.7 partners and females reported 1.3 partners, and only 18 percent reported consistent condom use. Runaways demonstrated moderately high AIDS knowledge and beliefs endorsing AIDS prevention. Condom use and abstinence were directly related to beliefs about preventing AIDS.

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