**5. Community-based epidemiologic research to address the impact of psychosocial factors and substance abuse on HIV/AIDS-risky behaviors**

This study is critical to the development of effective strategies to prevent and control a complex disease challenge such as HIV/AIDS, which is faced by millions of people globally. We conducted a community-based epidemiologic study that integrates multiple determinants – including psychosocial and SES factors – that facilitate HIV/AIDS transmission in all populations. The purpose of this study was to assess the quantitative contributions of each of these factors upon HIV/AIDS transmission. The objectives were: 1) to assess the relationships between psychosocial variables and HIV/AIDS-risky behaviors among PLWHA, and 2) to determine if significant differences exist in substance abuse among PLWHA both before and after their HIV infection status has been established.

#### **Materials and methods**

#### **Study design**

The data was collected by a questionnaire instrument survey of the HIV-positive clients of a community-based HIV/AIDS outreach facility (CBHAOF) located in Montgomery, Alabama, USA. The CBHAOF provides treatment and prevention services through education, quality services, and compassionate care for HIV/AIDS clients and their families in 27 counties in Alabama. In addition, the CBHAOF has a medical component/clinic that

Triple Challenges of Psychosocial Factors, Substance Abuse,

**5.1 Results** 

HIV/AIDS-risky behaviors.

0.01).

the differences between proportions in the matched-pair case.

and HIV/AIDS Risky Behaviors in People Living with HIV/AIDS 147

between the quantity of alcohol consumed and select risky sexual behaviors. A paired t-test was used to determine if significant differences existed in the prevalence of substance abuse before and after the knowledge of HIV infection status. The McNemar test was used to test

Table 2 illustrates standardized regression weights for psychosocial factors regarding HIV/AIDS-risky behaviors among PLWHA. The participants who indicated having lost interest in aspects of life that were important before establishing HIV infection status is significantly related to the use of drugs before sex (total effects' standardized regression coefficient = 0.11, p = 0.02); IDU (total effects' standardized regression coefficient = 0.28, p = <0.001); sharing the same syringe/needle with another person(s) to inject him/herself (total effects' standardized regression coefficient = 0.27, p <0.001); number of sexual partners within one year (total effects' standardized regression coefficient = 0.17, p = 0.001); sex with a prostitute(s) (total effects' standardized regression coefficient = 0.16, p = 0.004); and sex with a person(s) who inject drugs intravenously (total effects' standardized regression coefficient = 0.27, p <0.001). Further, Table 2 indicates that depression is strongly correlated with IDU (total effects' standardized regression coefficient = 0.16, p = 0.002); number of sexual partners within one year (total effects' standardized regression coefficient = 0.22, p <0.001); and condom use (total effects' standardized regression coefficient = 0.34, p <0.001). The regression coefficients for drinking alcohol before sex were also significantly related to all HIV/AIDS-risky behaviors. As indicated in Table 2, drinking alcohol before sex is correlated directly with using drugs before sex (total effects' standardized regression coefficient = 0.44, p <0.001); sharing the same syringe/needle with another person(s) who self-injects (total effects' standardized regression coefficient = 0.14, p <0.001); number of sexual partners within one year (total effects' standardized regression coefficient = 0.25, p <0.001); condom use (total effects' standardized regression coefficient = 0.17 p = 0.001); and sex with a prostitute(s) (total effects' standardized regression coefficient = 0.17, p = 0.003). The results suggest that drinking alcohol leads to promiscuity and then to increased

Further analysis of the association between psychosocial variables, especially depression, and HIV/AIDS-risky behaviors among PLWHA, shown in Table 3, indicates that IDU, syringe/needle sharing, substance abuse before sex, and sex with injecting drug users are significantly associated with depression. Among those participants reported to have used drugs intravenously, 60% were depressed compared to 40% not depressed. This indicates that PLWHA who experience depression were significantly more likely to report to have used drugs intravenously compared to non-depressed participants (p = 0.005). Results in Table 3 indicate also that depressed participants were more likely report having shared the same syringe/needle with another person to inject him/herself compared to participants who were not depressed (73 % versus 27 %, p <0.001). Depressed participants were significantly more likely to report alcohol consumption before sex compared to nondepressed participants (57 % versus 43 %, p = 0.002). Furthermore, depression is associated with drug use before sexual intercourse (p = 0.006) and sex with injecting drug users (p =

Table 1 shows a summary of the demographic characteristics of the respondents.

provides complete primary health care which includes physician visits and laboratory tests to diagnose HIV infection. The study questionnaire was designed to collect data on behaviors that could be associated with HIV/AIDS transmission in the Black Belt Counties (BBC) of Alabama, which stretch centrally across the state west to southeast. The BBC have a higher percentage (more than 50%) of African-American residents as compared to white residents. The questionnaire was pretested in collaboration with the CBHAOF to assess whether the materials were understood by and could be answered by the target participants. Tuskegee University's Institutional Review Board approved the final questionnaire, informed consent forms, and study protocol. The major modules of the questionnaire included: SES and demographic information; knowledge about HIV/AIDS and HIV testing; and substance abuse and other HIV/AIDS-risk behaviors before and after the knowledge of their HIV infection status. Participants filled out a questionnaire anonymously without any individual identifying information.

#### **Data collection procedures**

The data was collected in collaboration with the CBHAOF. The questionnaires and the informed consent forms were given to the facility staff to administer to and retrieve from study participants. The defined criteria to enroll study participants included: age equal to or greater than 18 years; being diagnosed as HIV positive by a laboratory test at the CBHAOF; or having AIDS diagnosed by a physician. A convenience sampling method was used to select the study group. During their regular medical visits eligible participants were informed about the study by the facility's staff. Each participant was approached individually at the end of his/her office visit by a trained interviewer who explained the goals of the study and requested consent for participation in the study. Although a convenience sampling method was used, almost all the clients approached were eligible and agreed to participate in the survey in one of two ways: 1) by signing or returning the consent form prior to their response to the questionnaire, or 2) by simply filling out the questionnaire at clinical sites. Participant's names were not included in the questionnaire, thus maintaining their anonymity.

A total of 341 questionnaires were distributed at the convenience of the participants and returned to CBHAOF staff in a sealed envelope. A total of 326 questionnaires were completed fully and returned; this represents a response rate of 96%. The remaining 15 questionnaires were returned to the facility but were not fully completed and as a consequence they were discarded and not used in the analysis. This represents a 4% refusal/dropout rate. Upon receiving the completed questionnaire CBHAOF staff gave each participant a Wal-Mart gift card valued at \$15.00. Tuskegee University provided the gift card as an incentive and a token of appreciation for completing the questionnaire. Researchers at the CCEBRA collected the completed questionnaires from the CBHAOF staff, kept the surveys in a secured location, and entered data into a FileMaker Pro 6.0v4 database.

#### **Statistical analyses**

The data was analyzed using SAS System for Windows (SAS Institute Inc. Version 9.0.1 Software). Demographic variables were summarized using descriptive statistics. A path analysis model used the Analysis of Moment Structures (AMOS) version 17.0 Software (Arbuckle et al., 1999) to examine the relationships between all variables of the hypothesized model. A chi-square test was used to examine the association between depression and substance abuse to predict HIV/AIDS-risky behaviors among PLWHA. Regression and Pearson's Correlation analysis were used to determine if significant correlations existed between the quantity of alcohol consumed and select risky sexual behaviors. A paired t-test was used to determine if significant differences existed in the prevalence of substance abuse before and after the knowledge of HIV infection status. The McNemar test was used to test the differences between proportions in the matched-pair case.

#### **5.1 Results**

146 Social and Psychological Aspects of HIV/AIDS and Their Ramifications

provides complete primary health care which includes physician visits and laboratory tests to diagnose HIV infection. The study questionnaire was designed to collect data on behaviors that could be associated with HIV/AIDS transmission in the Black Belt Counties (BBC) of Alabama, which stretch centrally across the state west to southeast. The BBC have a higher percentage (more than 50%) of African-American residents as compared to white residents. The questionnaire was pretested in collaboration with the CBHAOF to assess whether the materials were understood by and could be answered by the target participants. Tuskegee University's Institutional Review Board approved the final questionnaire, informed consent forms, and study protocol. The major modules of the questionnaire included: SES and demographic information; knowledge about HIV/AIDS and HIV testing; and substance abuse and other HIV/AIDS-risk behaviors before and after the knowledge of their HIV infection status. Participants filled out a questionnaire

The data was collected in collaboration with the CBHAOF. The questionnaires and the informed consent forms were given to the facility staff to administer to and retrieve from study participants. The defined criteria to enroll study participants included: age equal to or greater than 18 years; being diagnosed as HIV positive by a laboratory test at the CBHAOF; or having AIDS diagnosed by a physician. A convenience sampling method was used to select the study group. During their regular medical visits eligible participants were informed about the study by the facility's staff. Each participant was approached individually at the end of his/her office visit by a trained interviewer who explained the goals of the study and requested consent for participation in the study. Although a convenience sampling method was used, almost all the clients approached were eligible and agreed to participate in the survey in one of two ways: 1) by signing or returning the consent form prior to their response to the questionnaire, or 2) by simply filling out the questionnaire at clinical sites. Participant's names were not included in the questionnaire,

A total of 341 questionnaires were distributed at the convenience of the participants and returned to CBHAOF staff in a sealed envelope. A total of 326 questionnaires were completed fully and returned; this represents a response rate of 96%. The remaining 15 questionnaires were returned to the facility but were not fully completed and as a consequence they were discarded and not used in the analysis. This represents a 4% refusal/dropout rate. Upon receiving the completed questionnaire CBHAOF staff gave each participant a Wal-Mart gift card valued at \$15.00. Tuskegee University provided the gift card as an incentive and a token of appreciation for completing the questionnaire. Researchers at the CCEBRA collected the completed questionnaires from the CBHAOF staff, kept the surveys in a secured location, and entered data into a FileMaker Pro 6.0v4 database.

The data was analyzed using SAS System for Windows (SAS Institute Inc. Version 9.0.1 Software). Demographic variables were summarized using descriptive statistics. A path analysis model used the Analysis of Moment Structures (AMOS) version 17.0 Software (Arbuckle et al., 1999) to examine the relationships between all variables of the hypothesized model. A chi-square test was used to examine the association between depression and substance abuse to predict HIV/AIDS-risky behaviors among PLWHA. Regression and Pearson's Correlation analysis were used to determine if significant correlations existed

anonymously without any individual identifying information.

**Data collection procedures** 

thus maintaining their anonymity.

**Statistical analyses** 

Table 1 shows a summary of the demographic characteristics of the respondents.

Table 2 illustrates standardized regression weights for psychosocial factors regarding HIV/AIDS-risky behaviors among PLWHA. The participants who indicated having lost interest in aspects of life that were important before establishing HIV infection status is significantly related to the use of drugs before sex (total effects' standardized regression coefficient = 0.11, p = 0.02); IDU (total effects' standardized regression coefficient = 0.28, p = <0.001); sharing the same syringe/needle with another person(s) to inject him/herself (total effects' standardized regression coefficient = 0.27, p <0.001); number of sexual partners within one year (total effects' standardized regression coefficient = 0.17, p = 0.001); sex with a prostitute(s) (total effects' standardized regression coefficient = 0.16, p = 0.004); and sex with a person(s) who inject drugs intravenously (total effects' standardized regression coefficient = 0.27, p <0.001). Further, Table 2 indicates that depression is strongly correlated with IDU (total effects' standardized regression coefficient = 0.16, p = 0.002); number of sexual partners within one year (total effects' standardized regression coefficient = 0.22, p <0.001); and condom use (total effects' standardized regression coefficient = 0.34, p <0.001).

The regression coefficients for drinking alcohol before sex were also significantly related to all HIV/AIDS-risky behaviors. As indicated in Table 2, drinking alcohol before sex is correlated directly with using drugs before sex (total effects' standardized regression coefficient = 0.44, p <0.001); sharing the same syringe/needle with another person(s) who self-injects (total effects' standardized regression coefficient = 0.14, p <0.001); number of sexual partners within one year (total effects' standardized regression coefficient = 0.25, p <0.001); condom use (total effects' standardized regression coefficient = 0.17 p = 0.001); and sex with a prostitute(s) (total effects' standardized regression coefficient = 0.17, p = 0.003). The results suggest that drinking alcohol leads to promiscuity and then to increased HIV/AIDS-risky behaviors.

Further analysis of the association between psychosocial variables, especially depression, and HIV/AIDS-risky behaviors among PLWHA, shown in Table 3, indicates that IDU, syringe/needle sharing, substance abuse before sex, and sex with injecting drug users are significantly associated with depression. Among those participants reported to have used drugs intravenously, 60% were depressed compared to 40% not depressed. This indicates that PLWHA who experience depression were significantly more likely to report to have used drugs intravenously compared to non-depressed participants (p = 0.005). Results in Table 3 indicate also that depressed participants were more likely report having shared the same syringe/needle with another person to inject him/herself compared to participants who were not depressed (73 % versus 27 %, p <0.001). Depressed participants were significantly more likely to report alcohol consumption before sex compared to nondepressed participants (57 % versus 43 %, p = 0.002). Furthermore, depression is associated with drug use before sexual intercourse (p = 0.006) and sex with injecting drug users (p = 0.01).

Triple Challenges of Psychosocial Factors, Substance Abuse,

**The relationship between lost interests in aspects** 

**The relationship between depression and** 

behaviors among PLWHA

**The relationship between drinking alcohol before sex and** 

**of life and** 

and HIV/AIDS Risky Behaviors in People Living with HIV/AIDS 149

Variable Total effects p-value

Using drugs before sex 0.11 0.02 Injecting drugs intravenously (IDU) 0.28 <0.001 Needle sharing 0.27 <0.001 Number of sexual partners within 1 year 0.17 0.001 Sex with prostitutes 0.16 0.004 Sex with injection drug users 0.27 <0.001

Injection drug users 0.16 0.002 Number of sexual partners within 1 year 0.22 <0.001 Condom use 0.34 <0.001

Using drugs before sex 0.44 <0.001 Needle sharing 0.14 0.01 Number of sexual partners within 1 year 0.25 <0.001 Condom use 0.17 0.001 Sex with prostitutes 0.17 0.003 Table 2. The relationships between selected psychosocial variables and HIV/AIDS-risky

HIV/AIDS risky behaviors Depressed Not depressed

Used drugs intravenously 0.005 Yes (N=52) 31 60 21 40 No (N=238) 91 38 147 62 Shared the same syringe/needle with another person <0.001 Yes (N=37) 27 73 10 27 No (N=254) 95 37 159 63 Drinking alcohol before sexual intercourse 0.002 Yes (N=77) 44 57 33 43 No (N=205) 76 37 129 63 Drug use before sexual intercourse 0.006 Yes (N=40) 26 65 14 35 No (N=210) 82 39 128 61

Sex with injecting drug users 0.01 Yes (N=43) 27 63 16 37 No (N=171) 64 37 107 63

Table 3. Depression by substance abuse and other HIV/AIDS-risky behaviors

n % n % *p* value


Table 1. Demographic and socioeconomic characteristics of the participants

Demographic and socioeconomic characteristics n % Sex Female 136 42 Male 181 56 Transgender 4 1 Transsexual 5 2 Race African American 208 64 White (non-Hispanic) 94 29 Hispanic 10 3 Other races 14 4 Age group 18-29 53 19 30-39 86 30 40-49 104 37 50-59 34 12 60 and above 6 2 Marital Status Single 183 56 Married 47 15 Divorced 47 15 Separated 31 10 Widow (er) 3 1 Other 13 4 Employment Status Employed for wages 122 39 Unable to work 59 19 Unemployed 50 16 Student 25 8 Homemaker 25 8 Self-employed 18 6 Retired 12 4 Level of education Graduate school 11 3 College 4 years or more 50 15 College 1 year to 3 years 85 26 Grade 12 or GED 126 39 Grades 9 through 11 40 12 Grades 1 through 8 11 3 Level of income \$9,999 or under 97 31 \$10,000 to \$14,999 45 14 \$15,000 to \$19,999 38 12 \$20,000 to \$24,999 36 11 \$25,000 to \$29,999 23 7 \$30,000 to \$49,999 20 6 \$50,000 to \$74,999 13 4 Don't know 46 14

Table 1. Demographic and socioeconomic characteristics of the participants


Table 2. The relationships between selected psychosocial variables and HIV/AIDS-risky behaviors among PLWHA


Table 3. Depression by substance abuse and other HIV/AIDS-risky behaviors

Triple Challenges of Psychosocial Factors, Substance Abuse,

**6. Discussion** 

2008).

and HIV/AIDS Risky Behaviors in People Living with HIV/AIDS 151

The association between low SES and risk of HIV infection has been well documented in the scientific literature (Hargreaves, 2002; Solorio et al., 2002). The HIV/AIDS pandemic is most severe in the poorest countries, worldwide, and among people of color (UNAIDS, 1999). Similarly, HIV/AIDS prevalence in the U.S. is disproportionately high in poor communities and runs rampant among African Americans. Although HIV/AIDS affects all races in the U.S. there is no single explanation for why HIV/AIDS affects African Americans disproportionately. A combination of biomedical, behavioral, and SES factors, often working together conjointly, seems to be responsible for this health disparity. Poverty, income inequality, and lack of or limited access to appropriate and high-quality health care

programs are some of the social determinants that influence the health of PLWHA.

Studies have shown the prevalence of psychosocial problems not only to be common in PLWHA but related to increased high-risk behaviors. These include drug use before sex, sharing the same syringe/needle with another person to inject themselves, and having had multiple sexual partners. The findings suggest that psychosocial problems influence HIV/AIDS-risky behaviors and may contribute to the high probability of HIV infection within high-risk populations. The most plausible explanation for this finding is that psychosocial problems, such as depression, impair both physical and cognitive functioning and can interfere with the decision to practice safe sexual behaviors. Moreover, depression is a barrier to behavior change. Currently, treating depression is the most successful strategy to effectively reduce the risk of acquiring and spreading HIV/AIDS (Paterson et al., 2000). In this study, results confirmed that psychosocial variables related to HIV/AIDS-risky behaviors are complex. Thus, a detailed understanding of how psychosocial factors impact on HIV/AIDS risk-taking behaviors among PLWHA might be important for prevention and control purposes. Study results demonstrate substance abuse, especially alcohol, is linked to the tendency to have multiple partners and sexual intercourse without condoms. The findings demonstrated the prevalence of depression in PLWHA which occurs concurrently with substance abuse in this population. Participants significantly reduced alcohol intake post-diagnosis – a research finding that highlights the effectiveness of incorporating alcoholreduction strategies to reduce HIV/AIDS-risky behaviors - however, PLWHA should be advised not to drink excessive amounts of alcohol, which is associated with high-risk sexual and drug injection-related behaviors that increase the likelihood of HIV transmission (Dag,

The findings of this study also indicate that PLWHA continue to engage in HIV/AIDS risky behaviors after the knowledge of their HIV status. There are several possible explanations for this finding. First, with the advent of HAART in 1996 mortality among PLWHA decreased dramatically (Bouhnik et al., 2007). Most of the PLWHA who get therapeutic benefits from HAART may attain an improved quality of life and functional status with the alleviation of the physiological, social, and psychological consequences of HIV/AIDS. These gains may be accompanied by increases in HIV/AIDS-risky behaviors that include sharing the same syringe/needle with another person. Secondly, PLWHA may have unrealistic beliefs about the impact of HAART on disease transmission rates and therefore may perceive the consequences of transmitting HIV/AIDS as being less serious than in the past. The proven efficacy of HAART in reducing mother-to-child transmission of HIV/AIDS may reinforce these beliefs. PLWHA who have such beliefs may be less likely to use condoms consistently or may have a higher number of sexual partners than those who do not.

Findings about the participants' alcohol consumption, both before and after having established their HIV infection status, are presented in Table 4. The variables selected for analysis were about the consumption of alcoholic beverages and frequency and number of alcoholic beverages consumed before sex. A statistically significant difference (p = .001) was observed in the variable "drinking alcoholic beverages before sex" among the participants before and after establishing their HIV infection status (Table 4). The analysis of the question "Did you drink any alcoholic beverage such as beer, wine, wine coolers, or liquor before you had sexual intercourse the last time?" shows that before establishing their HIV infection status, 35% of the participants had consumed an alcoholic beverage before sex. In comparison, 28% of the participants indicated that they had consumed an alcoholic beverage before sex after establishing their HIV infection status. The difference between drinking alcohol before sexual intercourse – both before and after the knowledge of HIV infection status – among PLWHA is 18.50% with a 95% confidence interval (CI) from 8.07% to 27.07%; this is statistically significant (p = .0001). No significant differences were observed in other measures of HIV/AIDS-risky behaviors. These include frequency and quantity of alcohol consumed before sex, IDU, and sharing the same syringe or needle with another person (Table 4).


Table 4. The difference between drinking alcohol before and after establishing HIV infection status
