Meta-Analysis of Alcohol and Serodiscordant Condomless Sex Among People Living with HIV
While observational studies have found that alcohol consumption is associated with serodiscordant condomless sex among people living with HIV (PLHIV), no meta-analysis has yet examined this trend. We conducted a meta-analysis to synthesize empirical evidence on the association between alcohol and condomless sex with partners at risk of HIV acquisition. To meet inclusion criteria, studies: (1) specifically targeted PLHIV or provided stratified data for HIV-infected participants; (2) provided a quantitative measure of alcohol use; (3) provided a quantitative measure of condomless sex with serodiscordant partners; and (4) reported the results of statistical tests examining the relationship between alcohol use and serodiscordant condomless sex. Using random-effects models, weighted effect sizes were calculated. Three separate analyses were conducted to examine serodiscordant condomless sex in association with any alcohol consumption, binge/problematic drinking, and alcohol in a sexual context. A total of 36 independent effect sizes from 27 studies (including 25,065 HIV-infected participants) were pooled in the meta-analysis. Any alcohol consumption, binge/problematic drinking, and alcohol use in a sexual context were each associated with condomless sex with serodiscordant partners [OR 1.64 (95% CI 1.46–1.85); OR 1.65 (95% CI 1.14–2.39); OR 2.88 (95% CI 2.01–4.12), respectively]. Meta-analytic findings demonstrate a consistent positive relationship between alcohol use and serodiscordant condomless sex among PLHIV. Future public health programming for HIV-infected individuals needs to address the role of alcohol consumption in sexual risk-taking behavior.
KeywordsCondomless sex Alcohol HIV Meta-analysis
This research was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (T32-AA007583, PI: Leonard). The sponsor had no role in the study design, writing of the report, or collection, analysis, and interpretation of the data.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
References marked with an asterisk indicate studies included in the meta-analysis
- Azar, M. M., Springer, S. A., Meyer, J. P., & Altice, F. L. (2010). A systematic review of the impact of alcohol use disorders on HIV treatment outcomes, adherence to antiretroviral therapy and health care utilization. Drug and Alcohol Dependence, 112(3), 178–193.PubMedPubMedCentralCrossRefGoogle Scholar
- Blair, J. M., Fagan, J. L., Frazier, E. L., Do, A., Bradley, H., Valverde, E. E., … Skarbinski, J. (2014). Behavioral and clinical characteristics of persons receiving medical care for HIV infection—Medical Monitoring Project, United States, 2009. Morbidity and Mortality Weekly Report, 63(Suppl. 5), 1–22.Google Scholar
- *Bouhnik, A. D., Préau, M., Lert, F., Peretti-Watel, P., Schiltz, M. A., Obadia, Y., … VESPA Study Group. (2007a). Unsafe sex in regular partnerships among heterosexual persons living with HIV: Evidence from a large representative sample of individuals attending outpatients services in France (ANRS-EN12-VESPA Study). AIDS, 21(Suppl. 1), S57–S62.PubMedCrossRefGoogle Scholar
- *Bouhnik, A. D., Préau, M., Schiltz, M. A., Lert, F., Obadia, Y., Spire, B., & VESPA Study Group. (2007b). Unprotected sex in regular partnerships among homosexual men living with HIV: A comparison between sero-nonconcordant and seroconcordant couples (ANRS-EN12-VESPA Study). AIDS, 21(Suppl. 1), S43–S48.PubMedCrossRefGoogle Scholar
- *Brennan, D. J., Welles, S. L., Miner, M. H., Ross, M. W., Rosser, B. R., & Team, Positive Connections. (2010). HIV treatment optimism and unsafe anal intercourse among HIV-positive men who have sex with men: Findings from the positive connections study. AIDS Education and Prevention, 22, 26–37.Google Scholar
- Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health. Retrieved from http://www.samhsa.gov/data.
- *Chin-Hong, P. V., Deeks, S. G., Liegler, T., Hagos, E., Krone, M. R., Grant, R. M., & Martin, J. N. (2005). High-risk sexual behavior in adults with genotypically proven antiretroviral-resistant HIV infection. Journal of Acquired Immune Deficiency Syndromes, 40, 463–471.PubMedCrossRefGoogle Scholar
- Davey, D. J., Kilembe, W., Wall, K. M., Khu, N. H., Brill, I., Vwalika, B., … Gorbach, P. M. (2017). Risky sex and HIV acquisition among HIV serodiscordant couples in Zambia, 2002–2012: What does alcohol have to do with it? AIDS and Behavior, 21, 1892–1903. doi: 10.1007/s10461-017-1733-6.CrossRefGoogle Scholar
- Dia, A., Marcellin, F., Bonono, R. C., Boyer, S., Bouhnik, A. D., Protopopescu, C., … EVAL Study Group. (2010). Prevalence of unsafe sex with one’s steady partner either HIV-negative or of unknown HIV status and associated determinants in Cameroon (EVAL ANRS12-116 survey). Sexually Transmitted Infections, 86, 148–154.PubMedCrossRefGoogle Scholar
- Doyle, J. S., Degenhardt, L., Pedrana, A. E., McBryde, E. S., Guy, R. J., Stoové, M. A., … Hellard, M. E. (2014). Effects of HIV antiretroviral therapy on sexual and injecting risk-taking behavior: A systematic review and meta-analysis. Clinical Infectious Diseases, 59, 1483–1494.PubMedCrossRefGoogle Scholar
- *Golin, C., Marks, G., Wright, J., Gerkovich, M., Tien, H. C., Patel, S. N., … Quinlivan, E. B. (2009). Psychosocial characteristics and sexual behaviors of people in care for HIV infection: An examination of men who have sex with men, heterosexual men and women. AIDS and Behavior, 13, 1129–1142.PubMedPubMedCentralCrossRefGoogle Scholar
- Gorbach, P. M., Weiss, R. E., Jeffries, R., Javanbakht, M., Drumright, L. N., Daar, E. S., & Little, S. J. (2011). Behaviors of recently HIV-infected men who have sex with men in the year postdiagnosis: Effects of drug use and partner types. Journal of Acquired Immune Deficiency Syndromes, 56, 176–182.PubMedPubMedCentralCrossRefGoogle Scholar
- *Hasse, B., Ledergerber, B., Hirschel, B., Vernazza, P., Glass, T. R., Jeannin, A., … Swiss HIV Cohort Study. (2010). Frequency and determinants of unprotected sex among HIV-infected persons: The Swiss HIV Cohort Study. Clinical Infectious Diseases, 11, 1314–1322.Google Scholar
- Heijman, T., Geskus, R. B., Davidovich, U., Coutinho, R. A., Prins, M., & Stolte, I. G. (2012). Less decrease in risk behaviour from pre-HIV to post-HIV seroconversion among MSM in the combination antiretroviral therapy era compared with the pre-combination antiretroviral therapy era. AIDS, 26, 489–495.PubMedCrossRefGoogle Scholar
- Hess, K. L., Chavez, P. R., Kanny, D., DiNenno, E., Lansky, A., Paz-Bailey, G., & NHBS Study Group. (2015). Binge drinking and risky sexual behavior among HIV-negative and unknown HIV status men who have sex with men, 20 US cities. Drug and Alcohol Dependence, 147, 46–52.PubMedCrossRefGoogle Scholar
- Higgins, J. P. T., & Green, S. (Eds.). (2006). Cochrane handbook for systematic reviews of interventions. Chichester, UK: Wiley.Google Scholar
- Julio, R. S., Friedman, R. K., Cunha, C. B., De Boni, R. B., Cardoso, S. W., Torres, T., … Grinsztejn, B. (2015). Unprotected sexual practices among men who have sex with women and men who have sex with men living with HIV/AIDS in Rio de Janeiro. Archives of Sexual Behavior, 44, 357–365.PubMedCrossRefGoogle Scholar
- *Kahler, C. W., Wray, T. B., Pantalone, D. W., Kruis, R. D., Mastroleo, N. R., Monti, P. M., & Mayer, K. H. (2015a). Daily associations between alcohol use and unprotected anal sex among heavy drinking HIV-positive men who have sex with men. AIDS and Behavior, 19, 422–430.PubMedPubMedCentralCrossRefGoogle Scholar
- *Kalichman, S. C., Cherry, C., Kalichman, M. O., Amaral, C., White, D., Grebler, T., … Schinazi, R. F. (2011). Sexual HIV transmission and antiretroviral therapy: A prospective cohort study of behavioral risk factors among men and women living with HIV/AIDS. Annals of Behavioral Medicine, 42, 111–119.PubMedCrossRefGoogle Scholar
- Levy, M. E., Phillips, G., II, Magnus, M., Kuo, I., Beauchamp, G., Emel, L., … Mayer, K. (2017). A longitudinal analysis of treatment optimism and HIV acquisition and transmission risk behaviors among black men who have sex with men in HPTN 061. AIDS and Behavior. doi: 10.1007/s10461-017-1756-z.CrossRefPubMedGoogle Scholar
- Lipsey, M., & Wilson, D. (2001). Practical meta-analysis. Thousand Oaks, CA: Sage.Google Scholar
- Mizuno, Y., Purcell, D. W., Latka, M. H., Metsch, L. R., Ding, H., Gomez, C. A., & Knowlton, A. R. (2010). Is sexual serosorting occurring among HIV-positive injection drug users? Comparison between those with HIV-positive partners only, HIV-negative partners only, and those with any partners of unknown status. AIDS and Behavior, 14, 92–102.PubMedCrossRefGoogle Scholar
- *Morin, S. F., Steward, W. T., Charlebois, E. D., Remien, R. H., Pinkerton, S. D., Johnson, M. O., … Chesney, M. A. (2005). Predicting HIV transmission risk among HIV-infected men who have sex with men: Findings from the healthy living project. Journal of Acquired Immune Deficiency Syndromes, 40, 226–235.PubMedCrossRefGoogle Scholar
- National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health. (2008). Alcohol research: A lifespan perspective. Retrieved from http://pubs.niaaa.nih.gov/publications/AA74/AA74.htm.
- O’Leary, A., & Hatzenbuehler, M. (2009). Alcohol and AIDS. In P. Korsmeyer & H. R. Kranzler (Eds.), Addictive behaviors (3rd ed., pp. 104–111). Detroit, MI: Macmillan.Google Scholar
- Perry, N. S., Taylor, S. W., Elsesser, S., Safren, S. A., & O’Cleirigh, C. (2016). The predominant relationship between sexual environment characteristics and HIV-serodiscordant condomless anal sex among HIV-positive men who have sex with men (MSM). AIDS and Behavior, 20, 1228–1235.PubMedPubMedCentralCrossRefGoogle Scholar
- Rehm, J., Probst, C., Shield, K. D., & Shuper, P. A. (2017). Does alcohol use have a causal effect on HIV incidence and disease progression? A review of the literature and a modeling strategy for quantifying the effect. Population Health Metrics, 15(1), 4. doi: 10.1186/s12963-017-0121-9.PubMedPubMedCentralCrossRefGoogle Scholar
- Rosenberg, E. S., Millett, G. A., Sullivan, P. S., Del Rio, C., & Curran, J. W. (2014). Understanding the HIV disparities between black and white men who have sex with men in the USA using the HIV care continuum: A modeling study. Lancet HIV, 1(3), e112–e118.PubMedPubMedCentralCrossRefGoogle Scholar
- Scott-Sheldon, L. A., Carey, K. B., Cunningham, K., Johnson, B. T., Carey, M. P., & MASH Research Team. (2016). Alcohol use predicts sexual decision-making: A systematic review and meta-analysis of the experimental literature. AIDS and Behavior, 20(Suppl. 1), 19–39.PubMedCentralCrossRefGoogle Scholar
- Scott-Sheldon, L. A., Walstrom, P., Carey, K. B., Johnson, B. T., Carey, M. P., & MASH Research Team. (2013). Alcohol use and sexual risk behaviors among individuals infected with HIV: A systematic review and meta-analysis 2012 to early 2013. Current HIV/AIDS Reports, 10, 314–323.PubMedPubMedCentralCrossRefGoogle Scholar
- Shuper, P. A., Joharchi, N., & Rehm, J. (2016). Protocol for a controlled experiment to identify the causal role of acute alcohol consumption in condomless sex among HIV-positive MSM: Study procedures, ethical considerations, and implications for HIV prevention. AIDS and Behavior, 20, 173–184.PubMedCentralCrossRefGoogle Scholar
- Sterne, J. A. C., Newton, H. J., & Cox, N. J. (2009). Meta-analysis in Stata: An updated collection from the Stata journal. College Station, TX: Stata Press Publications.Google Scholar
- Steward, W. T., Remien, R. H., Higgins, J. A., Dubrow, R., Pinkerton, S. D., Sikkema, K. J., … Morin, S. F. (2009). Behavior change following diagnosis with acute/early HIV infection-a move to serosorting with other HIV-infected individuals: The NIMH Multisite Acute HIV Infection Study: III. AIDS and Behavior, 13, 1054–1060.PubMedPubMedCentralCrossRefGoogle Scholar
- *Tieu, H. V., Xu, G., Bonner, S., Spikes, P., Egan, J. E., Goodman, K., … Koblin, B. A. (2011). Sexual partner characteristics, serodiscordant/serostatus unknown unprotected anal intercourse and disclosure among human immunodeficiency virus-infected and uninfected black men who have sex with men in New York City. Sexually Transmitted Diseases, 38, 548–554.PubMedGoogle Scholar
- UNAIDS. (2016). Fact Sheet November 2016. Retrieved from http://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf.
- Venkatesh, K. K., De Bruyn, G., Lurie, M. N., Modisenyane, T., Triche, E. W., Gray, G. E., … Martinson, N. A. (2012). Sexual risk behaviors among HIV-infected South African men and women with their partners in a primary care program: Implications for couples-based prevention. AIDS and Behavior, 16, 139–150.PubMedPubMedCentralCrossRefGoogle Scholar
- Widman, L., Golin, C. E., Grodensky, C. A., & Suchindran, C. (2013a). Do safer sex self-efficacy, attitudes toward condoms, and HIV transmission risk beliefs differ among men who have sex with men, heterosexual men, and women living with HIV? AIDS and Behavior, 17, 1873–1882.PubMedPubMedCentralCrossRefGoogle Scholar
- Wilson, P. A., Kahana, S. Y., Fernandez, M. I., Harper, G. W., Mayer, K., Wilson, C. M., & Hightow-Weidman, L. B. (2015). Sexual risk behavior among virologically detectable human immunodeficiency virus-infected young men who have sex with men. JAMA Pediatrics, 7, 1–7.Google Scholar
- World Health Organization. (2014). Global status report on alcohol and health. Retrieved from http://apps.who.int/iris/bitstream/10665/112736/1/9789240692763_eng.pdf.