Predictors of substance use frequency and reductions in seriousness of use among persons living with HIV

Drug and Alcohol Dependence 77 (2005) 129–138

Predictors of substance use frequency and reductions in seriousness of use among persons living with HIV Marguerita Lightfoota,∗ , Tyson Rogersa , Ris¨e Goldsteina , Mary Jane Rotheram-Borusa , Susanne Maya , Sheri Kirshenbaumb , Lance Weinhardtc , Cathy Zadoretzkyd , Lauren Kittelb , Mallory Johnsone , Cheryl Gore-Feltonc , Stephen F. Morine b

a Center for Community Health, University of California, Los Angeles, CA 90024, USA HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY 10032, USA c Center for AIDS Intervention Research, Medical College of Wisconsin, Milwaukee, WI 53202, USA d Beth Israel Medical Center, New York, NY 10003, USA e Center for AIDS Prevention Studies, University of California, San Francisco, CA 94105, USA

Received 7 November 2003; received in revised form 7 May 2004; accepted 29 July 2004

Abstract Aims: To examine predictors of the current level of substance use and reductions in seriousness of substance use among adults living with HIV. Design: Cross-sectional survey. Setting: Four major metropolitan areas of the United States. Participants: Three thousand eight hundred six adults living with HIV. Measurement: Self-reported substance use, depression, and quality of life from audio computer assisted self-interviewing and computer assisted personal interviewing structured assessments. Findings: Recent substance use of persons living with HIV was classified as frequent (40%), occasional (32%), or abstinent (28%). Participants using drugs at a frequent level identified as heterosexual, had public insurance, and had higher levels of depression. Participants who reduced from a lifetime high seriousness in substance use were female, older, and knew their HIV status for a longer period of time. Conclusions: Screening and identification of substance use should be included in all treatment settings and community-based organizations serving adults living with HIV. © 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: HIV; Risk factors; Comorbidity

1. Introduction Alcohol and drug use by persons living with HIV (PLH) heightens the risk of HIV transmission by increasing the likelihood of unprotected sex, the number of sexual partners, particularly casual partners, and the exchange of sex for money or drugs (Dolezal et al., 2000; Edlin et al., 1994; Nadeau et al., 2000; Wang et al., 2000). Furthermore, alcohol and other drug use has direct negative consequences for the health of ∗

Corresponding author. Tel.: +1 310 794 6073. E-mail address: [email protected] (M. Lightfoot).

0376-8716/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.drugalcdep.2004.07.009

PLH such as poor nutrition, difficulties accessing medical care, and adhering to complex medical regimens (Palepu et al., 2004; Cook et al., 2001; Kim et al., 2001; Poundstone et al., 2001; Forrester et al., 2000; Taylor et al., 2000; Baum et al., 1997). Given the societal and individual health problems associated with increased risk of sexual transmission as a result of drug and alcohol use, greater knowledge regarding the factors associated with substance use by PLH is essential. Similar to earlier cohorts of PLH, a recent nationally representative sample of PLH in care (n = 2864 PLH) found significant problems with substance use (Bing et al., 2001; Galvan et al.,

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2002). Over 12 months, about half of PLH (51%) engaged in drug use, with 26% reporting “hard” drug use and 13% drug dependency (Bing et al., 2001). Alcohol use was even more common: 53% reported use in the past month and of those 15% drank heavily (Galvan et al., 2002). Previous research examining the effect of substance use on the health of PLH has primarily focused on injection drug users (Des Jarlais et al., 2003; Fisher et al., 1999) or employs substance use as a predictor of behaviors such as medication adherence or sexual risk behavior (Cook et al., 2001; Kwiatkowski and Booth, 1998; Mehta et al., 1997). However, there are likely to be very different consequences of substance use as a function of frequency of use. As PLH live longer and higher quality lives (Palella et al., 1998; Detels et al., 1998), refraining from sexual and substance use acts that could transmit HIV to others becomes more challenging and of greater public health significance. Recent reports of increasing rates of sexual risk acts and sexually transmitted diseases among PLH (Drucker et al., 2001; Scheer et al., 2001; Vanable et al., 2000) have often been attributed to the introduction of highly active antiretroviral therapy (HAART; Katz et al., 2002; Rietmeijer et al., 2003; Stolte et al., 2002; Vlahov et al., 2001; Wilson, 2001; Centers for Disease Control and Prevention, 2001). Given the advent of HAART and that data from a representative sample of PLH were collected pre-HAART, another examination of the substance use patterns of PLH is warranted. Furthermore, the resurgence of sexual risk behaviors among PLH has driven a prevention agenda that has focused on “prevention for positives” (Centers for Disease Control and Prevention, 2002). Given the association between sexual risk behaviors and substance use, this prevention agenda would be informed by a current examination of the substance use patterns of PLH. Our first goal is to examine behavioral patterns associated with three different types of substance use: abstinence, occasional, and frequent. Given the relationship between substance use and sexual risk behaviors and the elevated rates of alcohol and drug use among PLH, it is also important to examine the factors associated with reductions in consumption of alcohol and other drugs. These issues influence a PLH’s quality of life, mental health, and physical health, and they have important implications for the development of interventions designed to decrease HIV transmission behaviors. In particular, reduction or elimination of substance use and abuse may be useful or even an essential precursor to reduction of sexual transmission risk acts. Consequently, our second goal is to explore factors associated with reductions among PLH in the seriousness of substances used, from most serious use in lifetime to the 3 months prior to interview. To further understand alcohol and drug use among PLH, the current study examined data from a community-based sample of 3806 PLH participating in a secondary prevention trial in four major metropolitan areas of the United States. Although not drawn to be nationally representative, the sample was demographically reflective of the current HIV epidemic in the United States (Centers for Disease Control and Preven-

tion, 2001); the sample was predominately African American or Latino and included 26% woman and 13% injection drug users. Further, the present sample was recruited between April 2000, and January 2002, at which time HAART had been available for several years. Therefore, the image of the epidemic in the United States had substantially changed from a fatal to a more chronic and manageable condition. The sample also included PLH who had no usual source of health care nor were receiving or adhering to nationally recognized standards of care, in contrast to earlier research (Bing et al., 2001). Therefore, the current sample demonstrates much of the diversity among PLH currently evident in the HIV epidemic in the United States. The sample’s diversity is ideal for addressing this study’s goals: examining the frequency of substance use and exploring factors associated with reductions in the seriousness of substances used.

2. Methods 2.1. Study participants A total of 3819 PLH were recruited from community agencies, AIDS service organizations, and medical clinics in four cities (San Francisco, Los Angeles, New York City, and Milwaukee) for a clinical trial of an individually administered cognitive-behavioral intervention. Thirteen PLH did not fully complete the substance use section of the interview and therefore were eliminated from the analysis sample for this paper (n = 3806). Participants were required to be at least 18 years of age, speak English or Spanish, provide written informed consent, provide written medical documentation of their HIVpositive serostatus, to be free of severe neuropsychological impairment and psychosis based on interviewer observation, and not be currently involved in another behavioral intervention study related to HIV. 2.2. Procedures All procedures and forms were reviewed and approved by the sites’ Institutional Review Boards (IRB). Assessment interviews were conducted in English or Spanish in private settings in research offices, community-based organizations, and clinics in the four cities by trained interviewers using laptop computers to record responses (computer-assisted personal interviewing [CAPI]). The interview team was diverse in ethnicity, gender, and sexual orientation. Interviewers were centrally trained with the use of a detailed assessment manual and participated in an intensive 3-day training program. Interviewers were trained in a variety of areas, including psychosexual and substance-use assessments, sexual-abuse reporting, research ethics, and emergency procedures. To enhance the veracity of self-reports of sensitive behaviors and attitudes, sensitive questions (i.e., sexual and substance use behavior) were delivered via audio-computerassisted self-interviewing (ACASI; Turner et al., 1998). All

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interviews were audiotaped and quality assurance ratings were conducted on a random sample of 20% of all tapes to assess adherence to interview protocols, presentation style, use of forms and computer, and tape quality. All interviewers were found to perform at a satisfactory (90%) or higher adherence rating. Participants were compensated $50 for completing the 3 hours baseline interview. Participants needing childcare were also eligible to receive $10 to defray childcare costs.

2.3. Measures 2.3.1. Demographic and health status PLH reported their age, race/ethnicity, gender, selfidentified sexual orientation (homosexual, bisexual, heterosexual, other), marital status (single, married, divorced, widowed), educational level (below high school, high school, some college/technical school, college graduate), employment status, conviction of a crime (yes/no), medical insurance coverage (private, public, other), lifetime substance abuse treatment, and homelessness (been homeless or lived in a shelter). PLH also reported if they were currently linked to care, which was defined as reporting a usual HIV provider. In addition, health status indicators were recorded, including self-reported most recent CD4 count, HIV viral load, number of HIV-related physical symptoms, how much HIV-related physical symptoms bothered the participant (acuteness of symptom), the number of months living with HIV infection, time since learning of HIV status, and adherence to HAART (90% adherence over previous 3 days; AIDS Clinical Trial, Chesney et al., 2000). Finally, based on the Sexual Risk Behavior Assessment Schedule (Weinhardt et al., 1999), participants indicated the number of sexual partners, number of sexual acts with each partner, and number of times a condom was used. These data were used to calculate a dichotomous variable of engaging in only condom protected sex (yes, no) and the type of partners the participant engaged in sex with (opposite sex, both sexes, no sex, same sex).

2.3.2. Substance use Items assessed lifetime and recent (past 3 months) use of licit and illicit substances, including alcohol, cocaine/crack, sedatives, tranquilizers, stimulants, analgesics, inhalants, marijuana (both medicinal and illicit), hallucinogens, and heroin. Reports of prescription substances (e.g., methadone, Valium, prescribed medical marijuana) only included use in excess of prescribed doses. Participants were asked whether they had ever used each drug and the frequency of recent usage on a 9-point scale (1 = never; 2 = less than once a month; 3 = once a month; 4 = 2–3 times a month; 5 = once a week; 6 = 2–3 times a week; 7 = 4–6 times a week; 8 = once a day; 9 = more than once a day). When pertinent, probes were used to determine administration of substance (oral, inhaled, injected).

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2.3.3. Beck depression inventory (BDI) The BDI (Beck, 1967; Beck and Steer, 1993; α = 0.85) is a 21-item self-report measure, rated from 0 (absent) to 3 (severe) that assesses the severity of depression during the past week. The BDI is widely used, including with PLH (Griffin and Rabkin, 1997). 2.3.4. Quality of life The SF-36 from the Medical Outcomes Study (Ware et al., 1994) examines quality of life in multiple dimensions: general health, physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional, mental health, and reported health transition. The measure has been widely used and well validated in a variety of health contexts and populations (McHorney et al., 1993; McHorney et al., 1994; Ware et al., 1998). 2.4. Statistical analysis In order to assess the frequency of PLH’s current substance use, participants were classified into three categories by the frequency of recent (past 3 months) substance use: (1) abstinent—no alcohol or substance use; (2) occasional—frequency of alcohol use less than “once a day,” or frequency of use of other drugs less than “4–6 times a week,” and no injection drug use in the past 3 months; (3) frequent—alcohol frequency of more or equal to “once a day” or at least one drug with a frequency greater than or equal to “4–6 times per week” and/or injection drug use in the past 3 months. This classification is based on definitions used in the addiction severity index (ASI; McLellan et al., 1980) that indicate regular use as use of a substance greater or equal to three times a week. We used multinomial logistic regression (Agresti and Min, 2002) to model the relationship between potential predictors and the current frequency of substance use. The multinomial model generalizes binary logistic regression by allowing more than two levels of an outcome variable to be modeled simultaneously. The group reporting frequent drug use was used as the reference group. All predictors were included in the model. The predictors in the multinomial model were chosen by performing backward selection, with a P value criterion of 0.05 resulting in removal from the model. The set of predictors used as candidates for the model are described in Section 2.3. In order to examine changes in the “seriousness” of PLH’s substance use over time, participants were also classified based on an index of substances used in their lifetime and in the past 3 months (Hubbard et al., 1989). The three categories of substance use seriousness were: (1) high seriousness: hard drugs (cocaine, crack, speedball, MDMA, opiates, methamphetamine and heroin) or injection drug use; (2) medium seriousness: other drugs (methadone, inhalants, stimulants, ketamine, GHB, hallucinogens, sedatives, barbiturates, and steroids), excluding injection drug use and hard drugs; (3) low seriousness: no substance use or alcohol or marijuana

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use only. Thus, each participant’s substance use was of high, medium, or low seriousness for two time frames: lifetime and recent. The difference between lifetime and recent patterns was then analyzed. To examine reductions in seriousness of use over time, three models were estimated. We used continuation ratio logistic regression models (Fienberg, 1980; Allison, 1999) to describe the relationship between potential predictors of and reductions in lifetime versus recent seriousness of drug use. For each model the predictors were chosen by backwards selection with a P value criterion of 0.05 for predictor removal. The continuation ratio model is composed of several different binomial logistic models and each model refers to a different subset of PLH. The first model compares the PLH with a high lifetime seriousness level whose recent drug use stayed at a high level to those who reduced their seriousness of use to either medium or low seriousness. The second model examines those who decreased from a high seriousness level to medium seriousness as compared to those who decreased to a low level. This model lets us investigate factors that differentiate between these two degrees of change seen in some lifetime hard drug/injection users. The last model compares PLH with a lifetime medium seriousness level that stayed at a medium level to those who reduced to a low level. These three models allow us to see if different predictors are involved in the different types of substance use improvement. Variable selection methods were the same as for the frequency of use models and we confirmed adequacy of overall fit by the Hosmer–Lemeshow goodness-of-fit test (Hosmer et al., 1997). In all models, city of recruitment was controlled for in the analysis.

3. Results As shown in Table 1, the sample of 3806 PLH was mostly male (74%), with 43% of PLH self-reporting as heterosexual and 42% as homosexual. Almost half the sample was African American (48%), 33% was White or other, and 19% was Latino. A quarter of the sample (26%) reported less than a high school education, 50% reported being homeless or marginally housed sometime in their lifetime, and most PLH were not working (70%). A disturbing number of PLH (16%) were not linked to care and 46% had been in drug treatment during their lifetime. PLH reported minimal depression (M = 12.93). Table 2 describes the lifetime and recent substance use of the sample. Participants had used a variety of drugs in their lifetime, with alcohol (88%) and marijuana (74%) use being common. The most common recently used substances were alcohol (56%) and marijuana (39%). Few participants had never used substances (3%) or had only used alcohol or marijuana (16%). In contrast, about a quarter of PLH did not recently use any substances (28%), a quarter used only alcohol or marijuana (26%), and a quarter used hard drugs (24%). Approximately 8% of participants had injected drugs

Table 1 Demographic variables for sample (n = 3806) Variable

Percentage or mean (S.D.)

Background Site Los Angeles Milwaukee New York San Francisco

32% 11% 35% 22%

Ethnicity African American Hispanic White Other

48% 19% 26% 7%

Gender Male Female

74% 26%

Age

41.48 (7.68)

Sexual orientation Heterosexual Homosexual Bisexual Other

44% 42% 12% 2%

Education Below high school High school Some college/tech school College graduate or more

26% 27% 33% 14%

Homeless—lifetime Convicted of a crime

50% 48%

Physical health Years since learned HIV+ CD4 count Number of symptoms Symptom stress

8.43 (4.67) 439.44 (298.34) 12.44 (5.68) 36.16 (19.82)

Type of medical insurance Private Public None

15% 70% 15%

Not linked to care

16%

Adherence to ART Not adherent Adherent Not on ART

27% 47% 26%

Substance abuse treatment

46%

Hepatitis B—lifetime B—recent C and/or D—lifetime C and/or D—recent

34% 2% 32% 3%

Sexual behavior Recent sexual behavior Opposite sex Same sex Both sexes No sex

34% 39% 4% 23%

Protected sex only

60%

M. Lightfoot et al. / Drug and Alcohol Dependence 77 (2005) 129–138 Table 1 (Continued) Variable

Percentage or mean (S.D.)

Mental health Beck depression inventory

12.93 (8.96)

Quality of life (SF-36) Physical functioning Role-physical Bodily Pain General Health Vitality Social Functioning Role-Emotional Mental Health Health Transition

70.21 (24.83) 55.47 (39.95) 49.68 (9.84) 50.82 (15.78) 49.53 (22.25) 50.65 (13.92) 51.24 (42.59) 35.37 (20.81) 39.90 (29.74)

recently. When examining univariable associations between predictor variables and frequency of PLH’s current substance use, almost all of the associations were statistically significant. 3.1. Frequency of substance use PLH were classified with respect to recent substance use as abstinent (28%), occasional (40%), or frequent (32%). Table 3 shows the results of the multinomial logistic regression modeling to examine relationships between predictors and frequency of current substance use. The odds ratios in Table 3 reflect the relative probabilities of the three frequency classifications for different predictors. This enabled us to examine the variables that uniquely characterized and distinguished the different levels of substance use frequency. Under the multinomial logistic model, we calculated odds ratios, comparing abstinent users to frequent users, occasional users to frequent users, and abstinent users to occasional users for each predictor in the model. We then characterized each substance use group by the predictors with odds ratios that were statistically significant. For example, in

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the abstinent versus frequent comparison, the odds ratio describing the relationship between a previous hepatitis C or D infection is 0.68 (Table 3). In the occasional versus frequent comparison, the odds ratio for hepatitis C/D is 0.57. These two odds ratios are both significantly less than one. This result indicates that frequent users are characterized by an elevated proportion of hepatitis C/D infection relative to both abstinent and occasional substance users. Adding interactions to the model one at a time, we found one significant interaction, depression (as measured by Beck’s depression inventory) by the mental health measure of the SF-36. The odds of being abstinent as opposed to using substances frequently or occasionally were either not associated or less strongly associated with the level of depression measured by the Beck depression inventory and SF-36 mental health index score by themselves. An increase in depression score and SF-36 mental health score was associated with lower odds of being abstinent versus a frequent or occasional user. For occasional versus frequent use, there was no interaction effect between depression and mental health. In addition, participants using substances at a frequent level were more likely to be African American than White. In terms of health, frequent users were more likely to be infected with hepatitis C or D, and more likely to report public insurance rather than no insurance. They also tended to have been convicted of a crime. The identified variables did not distinguish occasional users from frequent users or those who were abstinent. Those who abstained from drug use tended to be female and reported sex with individuals of the opposite sex more than those who engaged in same gender sex. Interestingly, abstainers seemed to experience fewer adverse health symptoms. However, abstainers were more likely to report that their symptoms bothered them. Abstainers were also more likely to report higher levels of vitality as indicated on the SF-36. 3.2. Reduction in seriousness of substance use

Table 2 Lifetime and recent illicit substance use Substance name

Lifetime percentage (%)

Recent percentage (%)

Alcohol Barbituates Cocaine Crack GHB Hallucinogens Heroin Inhalants Ketamine Marijuana MDMA Methadone Opiates Sedatives Speedball Steroids Stimulants

88 14 59 50 5 32 28 29 7 75 13 15 13 22 20 6 32

56 1 17 20 2 2 6 10 2 39 3 7 4 7 3 2 11

Table 4 shows the results of continuation ratio modeling to examine variables related to reduction in the seriousness of substances used from lifetime to recent. 3.2.1. Any reduction from high seriousness Model A shows the results from the model focusing on the probability of decreasing the seriousness of substances used to either medium or low versus maintaining a high seriousness level of use. Of the 2646 participants reporting high seriousness of use in their lifetime, 52% reduced the seriousness of their substance use and 48% remained at a recent level of high seriousness. Females were almost twice as likely as males to reduce the seriousness of their substance use. Similarly, older participants and those who have known their HIV status for a longer period of time were more likely to reduce the seriousness of their substance use. Homeless participants were less likely to reduce their substance use. Both bisexual

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Table 3 Main effects of multinomial logistic regression model to examine relationships between predictors and frequency of substance use (n = 3615) Factor

Abstinent/frequent

Occasional/frequent

Abstinent/occasional

Site Los Angeles Milwaukee New York San Francisco

1.65 (1.26, 2.16)∗ 1.43 (0.98, 2.09) 1.50 (1.14, 1.98)∗ 1.00

1.34 (1.06, 1.68)∗∗ 1.93 (1.41, 2.64)∗ 1.20 (0.94, 1.53) 1.00

1.23 (0.95, 1.61) 0.74 (0.52, 1.06) 1.26 (0.95, 1.65) 1.00

Gender Female Male

1.46 (1.17, 1.83)∗ 1.00

1.01 (0.81, 1.27) 1.00

1.44 (1.16, 1.80)∗ 1.00

Ethnicity African American Hispanic Other White

1.90 (1.48, 2.45)∗ 1.57 (1.14, 2.15)∗ 0.93 (0.63, 1.37) 1.00

1.67 (1.35, 2.07)∗ 1.28 (0.96, 1.69) 0.73 (0.52, 1.02) 1.00

1.14 (0.89, 1.46) 1.23 (0.90, 1.68) 1.27 (0.85, 1.91) 1.00

Recent sexual behavior Opposite sex Both sexes No sex Same sex

1.75 (1.34, 2.27)∗ 0.59 (0.34, 1.02) 1.55 (1.18, 2.04)∗ 1.00

0.92 (0.72, 1.16) 0.85 (0.56, 1.27) 0.74 (0.57, 0.95)∗∗ 1.00

1.91 (1.48, 2.45)∗ 0.70 (0.41, 1.20) 2.11 (1.63, 2.74)∗ 1.00

Only condom protected sex Yes No

1.79 (1.45, 2.21)∗ 1.00

1.24 (1.03, 1.49)∗∗ 1.00

1.45 (1.18, 1.77)∗ 1.00

Lifetime hepatitis C or D infection Yes No

0.68 (0.55, 0.82)∗ 1.00

0.57 (0.48, 0.69)∗ 1.00

1.18 (0.96, 1.44) 1.00

Substance abuse treatment Yes No

1.52 (1.25, 1.86)∗ 1.00

0.53 (0.44, 0.63)∗ 1.00

2.87 (2.37, 3.48)∗ 1.00

Adherence to ART Adherent Not on ART Not adherent

1.74 (1.39, 2.17)∗ 0.86 (0.67, 1.12) 1.00

1.27 (1.04, 1.55)∗∗ 0.94 (0.75, 1.18) 1.00

1.37 (1.11, 1.70)∗ 0.95 (.73, 1.23) 1.00

Medical insurance Private None Public

1.32 (0.98, 1.78) 1.46 (1.10, 1.93)∗ 1.00

1.37 (1.07, 1.76)∗∗ 1.44 (1.13, 1.84)∗ 1.00

0.96 (0.73, 1.27) 1.01 (0.78, 1.31) 1.00

Convicted of a crime Yes No

0.71 (0.58, 0.87)∗ 1.00

0.68 (0.56, .81)∗ 1.00

1.04 (0.86, 1.27) 1.00

Number of symptomsa

0.93 (0.88, 0.98)∗ 1.00

1.02 (0.97, 1.06) 1.00

0.92 (0.87, 0.96)∗ 1.00

Acuteness of symptomsa

1.02 (1.00, 1.03)∗∗ 1.00

1.00 (0.98, 1.01) 1.00

1.02 (1.01, 1.04)∗ 1.00

SF-36 vitalitya

1.01 (1.00, 1.02)∗∗ 1.00

1.00 (1.00, 1.01) 1.00

1.01 (1.00, 1.01)∗∗ 1.00

SF-36 health transitiona

0.99 (0.99, 1.00) 1.00

1.00 (0.99, 1.00) 1.00

1.00 (0.99, 1.00) 1.00

0.71 (0.54, 0.93)∗∗ 0.76 (0.57, 1.00) 0.35 (0.23, 0.54)∗ 1.00

0.73 (0.58, 0.93)∗ 1.00 (0.78, 1.29) 0.75 (0.51, 1.11) 1.00

0.97 (0.74, 1.26) 0.76 (0.58, 1.00)∗∗ 0.47 (0.31, 0.70)∗ 1.00

Interaction BDI only SF-36 MH only Beck and SF-36 MHb Neither a b ∗ ∗∗

For continuous predictors, reported odds ratios are for a two standard deviation change in the predictor (i.e., ±1 standard deviation). A unit is a two standard deviation change in Beck and MH. P < 0.01. P < 0.05.

M. Lightfoot et al. / Drug and Alcohol Dependence 77 (2005) 129–138 Table 4 Continuation ratio models examining variables related to reduction in the seriousness of substances used from lifetime to recent Aa OR Gender Female Male

1.98b 1.00

Bb 95% CI 1.61

2.45

Ethnicity Hispanic Black Other White

OR

95% CI

1.49a 1.00

1.03

2.13

1.42 3.20b 1.03 1.00

0.93 2.17 0.60

2.18 4.72 1.78

Education Below high school Some college/tech school College graduate or more High school

1.24 0.87 0.76 1.00

0.99 0.71 0.57

1.55 1.07 1.01

Homeless (lifetime)

0.63b

0.54

0.75

1.38a

1.01

1.88

Age (per decade)

1.35b

1.20

1.52

0.77a

0.63

0.93

Self-reported sexual identity Heterosexual Bisexual Other Homosexual/gay

1.08 0.71b 0.44b 1.00

0.87 0.55 0.25

1.36 0.93 0.79

Marriage status Married Divorced/separated Widowed Never married

0.97 0.77a 0.63a 1.00

0.69 0.63 0.41

1.36 0.95 0.98

1.02a

1.00

1.04

Years since learned HIV status (per year)

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ness. Finally, younger participant were less likely to reduce to lower seriousness. 3.2.3. Reduction from medium seriousness Finally, we examined participants with lifetime medium seriousness who reduced to low versus remaining at a medium level. However, none of the investigated variables remained in the model. 3.2.4. Cross-tabulation of recent frequency and recent seriousness We examined the cross-tabulation of recent substance use frequency by reduction in seriousness of substances used. There is perfect correlation for the abstinent and injection drug users because subjects with zero frequency were always low seriousness and subjects with any injection drug use were always high seriousness. Therefore, excluding these two groups of participants, we examined the cross-tabulation of recent seriousness (low, medium, high) and frequency (occasional, frequent). For occasional users, 56% reported low seriousness, 15% medium seriousness, and 29% high seriousness of substances used. While a quarter of occasional users were using substances of high seriousness, occasional users reported predominately low seriousness of substances used. For frequent users, 27% reported low seriousness, 27% medium, and 46% high seriousness of substances used. Although alcohol or marijuana was being used frequently by a quarter of PLH, the substances that were predominately abused were of high seriousness. 4. Discussion

a

Model A: for probability of decreasing lifetime highest seriousness of hard drugs/IDU to either medium or low seriousness versus maintaining high seriousness (n = 2646). b Model B: for probability of decreasing lifetime high seriousness of substance use to low seriousness versus decreasing to medium seriousness (n = 1367).

participants and participants reporting their sexuality as other indicated being less likely to reduce the seriousness of their substance use in comparison to gay participants. Divorced and widowed individuals were also less likely to reduce their substance use. 3.2.2. Reduction from high seriousness: medium versus low Model B in Table 4 depicts the results of a model restricted to the 1367 PLH who reduced their lifetime high seriousness of use, focusing on factors differentiating the 83% of PLH who reduced their use to low seriousness versus the 17% who reduced to medium seriousness. Females were more likely than males to reduce to low as opposed to medium seriousness. Furthermore, African Americans were three times as likely as their White counterparts to reduce to low seriousness. While the earlier finding indicated homeless participants were less likely to reduce the seriousness of the substances used, those homeless participants who did reduce were significantly more likely to reduce to low serious-

Similar to findings in other cohorts, PLH in this sample were seriously involved in substance use during their lifetimes. While alcohol was the most commonly used substance and marijuana the most commonly used drug, 63% of participants had used hard drugs at some time in their lives. Almost half of PLH who had used hard drugs in their lifetime continued to use hard drugs recently, suggesting the pattern of substance use is habitual as opposed to reflecting mere experimentation. Furthermore, about 40% of PLH recently reported frequent levels of substance use and almost a third of PLH reported recent occasional use. These findings are troubling given the negative health consequences to PLH themselves, and the increased risks of transmission of HIV to others as a result of unprotected sex. These data suggests a more serious and frequent substance use problem among PLH than was found in the nationally representative sample of PLH in treatment settings. Unlike the representative sample, our sample of PLH was recruited from a number of different community sources and included a significant number of PLH without a regular source of medical care. Therefore, the data from this community sample suggest the need for services to address substance abuse, particularly in large urban areas. When examining factors distinguishing frequency of use, health is a significant factor for those who abstain from sub-

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stance use. PLH who abstain from substances report better physical health. Abstainers have fewer health symptoms and higher vitality. Abstainers are also distinguished from occasional or frequent users by their lower levels of depression and better mental health functioning. However, this group of PLH also reports that while they have few physical symptoms, those symptoms bother them more than those reported by the other groups. Given the limitation of cross-sectional data, we are unable to determine causality. It is unclear from this data if PLH are abstaining from substances because physical symptoms are more prominent in their lives or if the physical symptoms make substance use unfeasible. It may also be that abstainers are more bothered by their physical symptoms because they are not experiencing the self-medicating effects occasional or frequent drug users may be. Nevertheless, these findings illustrate the health benefits for PLH of abstaining from substance use and the need for interventions that assist PLH to stop using. In contrast, PLH who use at frequent levels report a constellation of unhealthy behaviors. Besides frequent use of substances, this group of PLH was more likely to be diagnosed with hepatitis C or D and to have been convicted of a crime. Further, in general, PLH who use substances frequently are using drugs of high seriousness, such as crack and heroin. These data suggest that there are a significant number of PLH that are in need of substance abuse treatment. Given the co-infection with hepatitis, there is a significant need for comprehensive interventions and programs for PLH that are abusing substances. Furthermore, since abusers are more likely to have public health insurance, it is important to provide easily accessible and publicly supported substance abuse treatment. Funding cuts for substance abuse treatment will be devastating, potentially resulting in a significant group of very sick PLH that overburden the public health care system. In examining the seriousness of the substances used by PLH, approximately 55% of PLH reduced the seriousness of the substances in their lifetime, and the reduction was most likely to be to low seriousness. Again, given that almost half of PLH who reported a lifetime of high seriousness in the drugs used continued to use hard drugs (a similar pattern emerged for occasional users), the pattern of substance use seems to reflect long-term use as opposed to experimentation early in life. When examining the factors associated with the probability of reducing seriousness in substance use, whether reducing from a lifetime level of high or medium, the most significant factor was time since HIV diagnosis. The longer the PLH knew their status, the more likely they were to reduce the seriousness of their substance use. The data are limited in that we do not know if the reduction in seriousness occurred prior to or after HIV diagnosis. Collecting retrospective data can be unreliable; therefore, we queried whether lifetime use had ever occurred, not frequency of use over lifetime. A limitation of this approach is the degree of change in frequency over time cannot be addressed. However, these findings support other research that indicates reductions in risk behaviors occur when an individual learns their HIV-positive status

(Rotheram-Borus et al., 2001; Marks et al., 1999; Kalichman et al., 1997; Wolitski et al., 1997). Therefore, the early detection of HIV has implications for not only reducing future transmission, but also possible reduction in the seriousness of substances used by PLH. Reduction in the seriousness of substances used, whether from high or low lifetime seriousness, was most often made by women. This association between gender and substance use reduction is consistent with previous research indicating that women who use are more likely than men to stop using (Shand and Mattick, 2002; Sterk et al., 1999). There were also strong associations between not reducing the seriousness of substances used and instability in other aspects of life. PLH who report homeless or who have been divorced are less likely to reduce the seriousness of the substances they use. Again, the cross-sectional nature of these data limits our ability to determine if the seriousness of substances is causing the instability in housing or relationships; however, the evidence indicates the varying needs of those who use serious substances and the need for comprehensive programs. Some of the estimated effects (Table 4) potentially might be due to regression towards the mean, if such effect acts differentially for the different groups investigated. If we assume that the only “reason” for a reduction of seriousness of drug use is (non-differential) regression towards the mean, then we should find an odds ratio of one when comparing females to males (and the regression towards the mean “effect” would be included in the intercept term). Thus, the finding, for example, that females are about twice as likely as males to reduce their seriousness of drug use from hard drugs/IDU to either medium or low seriousness (Table 4, Model A) either represents differences in the reduction pattern or represents differential regression towards the mean. We believe that in either case these differences are of interest and further research based on longitudinal data could help illuminate such potential differences. A major strength of this study is the sample. While not a representative sample, it is demographically reflective of the current HIV epidemic in the United States (Centers for Disease Control and Prevention, 2001). Unlike HCSUS, this large sample includes PLH who were not receiving regular medical care or receiving care outside of general outpatient settings such as a hospital emergency room. However, several limitations of this study should be recognized. First, we did not use formal diagnostic interviews for substance use disorders. Our measures assessed self-reported levels of substance use and are, therefore, a proxy for clinical dependence or abuse. Due to these classifications, results should be interpreted with caution. For example, while alcohol use is not considered as much of a problem as other substances, the health and societal consequences of “dependent” drinking can be much more devastating than those of occasional snorting or smoking of cocaine. Second, lifetime measures and doses of substance abuse treatment were not collected in the present study; they are important factors in examining frequency and reductions of seriousness in substances used

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and should be included in future research. Third, as indicated earlier, because this is a cross-sectional study, causal inferences cannot be made from associations. However, this study suggests that future longitudinal research is warranted. Despite these limitations, this study has important implications. These data suggest a high level of substance use among persons living with HIV. Given the health risks posed by substance use and its association with reduced medication adherence, data suggest that substance abuse treatment is essential in the care of PLH. Therefore, screening and identification of substance misuse and abuse, as well as referral for additional services, should be included in all interventions aimed at improving the physical functioning, mental health, and quality of life of those living with HIV.

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University of California, Los Angeles; Hannah Wolfe, Ph.D., Rachel Wolfe, Ph.D., St. Luke’s-Roosevelt Medical Center, New York; Lennie Wong, Ph.D., University of California, Los Angeles. Data Management and Analytic Support: Philip Batterham, M.A., Tyson Rogers, M.A., University of California, Los Angeles. Site Project Coordinators: Kristin Hackl, MSW, Medical College of Wisconsin, Milwaukee; Daniel Hong, M.A., Karen Huchting, B.A., University of California, Los Angeles; Joanne D. Mickalian, M.A., University of California, San Francisco; Margaret Peterson, MSW, Medical College of Wisconsin, Milwaukee. NIMH: Christopher M. Gordon, Ph.D., Dianne Rausch, Ph.D., Ellen Stover, Ph.D., National Institute of Mental Health, Bethesda, Maryland. References

Acknowledgements Authors would like to thank the following: The NIMH Healthy Living Trial Group. Research Steering Committee (site principal investigators and NIMH staff collaborator)—Margaret A. Chesney, Ph.D., University of California, San Francisco; Anke A. Ehrhardt, Ph.D., New York State Psychiatric Institute/Columbia University, New York; Jeffrey A. Kelly, Ph.D., Medical College of Wisconsin, Milwaukee; Willo Pequegnat, Ph.D., National Institute of Mental Health, Bethesda, Maryland; Mary Jane Rotheram-Borus, Ph.D., University of California, Los Angeles. Collaborating Scientists—Co-principal Investigators, and Investigators: Eric G. Benotsch, Ph.D., University of California, Los Angeles; Michael J. Brondino, Ph.D., Sheryl L. Catz, Ph.D., Medical College of Wisconsin, Milwaukee; Edwin D. Charlebois, Ph.D., MPH, University of California, San Francisco; Don C. DesJarlais, Ph.D., Beth Israel Medical Center, New York; Naihua Duan, Ph.D., University of California, Los Angeles; Theresa M. Exner, Ph.D., University of California, Los Angeles; Rise B. Goldstein, Ph.D., MPH, University of California, Los Angeles; Cheryl Gore-Felton, Ph.D., Medical College of Wisconsin, Milwaukee; A. Elizabeth Hirky, Ph.D., New York State Psychiatric Institute/Columbia University, New York; Mallory O. Johnson, Ph.D., University of California, San Francisco; Robert M. Kertzner, M.D., Sheri B. Kirshenbaum, Ph.D., Lauren E. Kittel, Psy.D., Robert Klitzman, M.D., New York State Psychiatric Institute/Columbia University, New York; Martha Lee, Ph.D., University of California, Los Angeles; Bruce Levin, Ph.D., New York State Psychiatric Institute/Columbia University, New York; Marguerita Lightfoot, Ph.D., University of California, Los Angeles; Stephen F. Morin, Ph.D., University of California, San Francisco; Steven D. Pinkerton, Ph.D., Medical College of Wisconsin, Milwaukee; Robert H. Remien, Ph.D., New York State Psychiatric Institute/Columbia University, New York; Fen Rhodes, Ph.D., University of California, Los Angeles; Susan Tross, Ph.D., New York State Psychiatric Institute/Columbia University, New York; Lance S. Weinhardt, Ph.D., Medical College of Wisconsin, Milwaukee; Robert Weiss, Ph.D.,

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