**2. The relationship between psychosocial factors and HIV/AIDS-risky behaviors**

A substantial amount of literature indicates depression is one of the most commonly occurring mental disorders identified among PLWHA. HIV/AIDS, its related infections, and the anti-viral drugs used to treat these illnesses can cause depression along with number of other psychiatric disorders (Desquilbet et al., 2002). Psychosocial problems have been associated also with HIV/AIDS-risky behaviors, non-adherence to medications, and shortened survival (Farinpour et al., 2003; Cook et al., 2004). Despite the prevalence of psychosocial distress experienced by PLWHA, the available body of evidence indicates that depression is frequently undiagnosed and goes untreated on a large scale. For example, in a large cohort of patients undergoing care for HIV/AIDS in the U.S., nearly half of those who met the criteria for major depression had no mention of such a diagnosis in their medical records (Asch et al., 2003); and one-third of PLWHA who needed psychosocial health services were not receiving them (Taylor et al., 2004).

However, health care service providers and associated facilities may be unaware of the depressive experiences of their HIV/AIDS patients and the effects these experiences can have on both behaviors and health outcomes. As a result, prevention and treatment of depression and provision of psychosocial support are often neglected in PLWHA, despite the fact that they are critical components of their health care. So, to support and promote mental health throughout the lifespan of the illness a number of interventions, including psychosocial support and basic counseling for depression, are required. As the medical community adapts to managing HIV/AIDS as a chronic disease, understanding the conjoint influence of depression and substance abuse on HIV/AIDS risky behaviors is very important. Failure to recognize these variables may endanger both HIV/AIDS patients and others in the community.

Studies of patients who seek HIV/AIDS treatment or preventive health services have reported a fairly high prevalence of psychosocial problems including depression, anxiety, and hostility (Kalichman, 2000; Cohen et al., 2002). Other research shows that psychosocial variables, such as depression and other mental health problems, drug or alcohol addictions, or any combination of these are most commonly prevalent among PLWHA (Moore et al., 2008; Wyatt et al., 2002; Whetten et al., 2006). It is estimated that up to 50% of PLWHA suffer from a mental illness, such as depression, and 13% have both mental illness and substance abuse issues (Bing et al., 2001). The same study indicates also that one-half of adults living with HIV/AIDS had symptoms of a psychiatric disorder; 19% had signs of substance abuse; 13% had co-occurring substance abuse and mental illness (Bing et al., 2001); and one-half of PLWHA had depression (Lesser, 2008).

Triple Challenges of Psychosocial Factors, Substance Abuse,

transmission through IDU (Aceijas et al., 2004).

negative MSM participants (Chen et al., 2002).

**population level** 

and HIV/AIDS Risky Behaviors in People Living with HIV/AIDS 139

national representative sample of current alcohol use among PLWHA showed a prevalence

Needles and syringes are the second most common route of HIV transmission in the U.S. [World Health Organization (WHO)/UNAIDS, 2004; WHO, 2005]. Each year more than 8,000 people are newly infected with HIV through the sharing of HIV-contaminated syringes and needles (CDC, 2005). Since the beginning of the HIV pandemic, the CDC (2005) estimates that IDU has directly and indirectly accounted for approximately one-third (36%) of AIDS cases in the U.S. Globally, approximately 10% of HIV infections are a direct result of

HIV/AIDS intervention studies that target risky behaviors in various groups have been conducted in an assortment of settings. A study in France, for example, found that the proportion of HIV-positive patients reporting sexual behavior at risk for HIV transmission increased from 5.1% in 1998 to 21.1% in 2001-2002 (Desquilbet, 2002). In addition it has been shown that risky sexual behaviors, including unprotected sex and multiple sexual partners, occur among PLWHA (Schiltz and Sandfort, 2000). For example, a study by Binson (1993) indicates that a considerable percentage of PLWHA (range of 10% to 60% depending on the specific sex acts) continue to engage in unprotected sexual behaviors that place others at risk for infection and place themselves at risk for contracting secondary STDs (e.g., syphilis) which may accelerate HIV infection (Lowry, 1994). In another study conducted between 1999 and 2001 in San Francisco, California, found that the proportion of MSM reporting to have had unprotected anal sex with two or more partners of unknown serostatus increased from 19% to 25% for HIV positive MSM, compared to an increase from 10% to 15% for HIV-

The reasons that underlie the correlation between substance abuse and high-risk behaviors among PLWHA have been described to include: decreased inhibitions and risk perception; belief that alcohol and other drugs enhance sexual arousal and performance; deliberate substance abuse as an excuse for high-risk behaviors; and the indirect association that bars (taverns) are common places to meet potential sexual partners. The mechanisms by which substance abuse influences risky behaviors are associated with situational factors, such as cognitive impairment, social modelling, or the fact that substance abuse and risk-taking

behaviors often occur in the same social venues (Abderhalden, 2007).

groups have been developed by the CCEBRA at Tuskegee University.

**4. Epidemiologic modelling to study HIV/AIDS dynamics at the macro-**

Computational models and simulations are emerging as vital research tools in the fields of epidemiology, biology, and other sciences. Increasingly, scientific researchers are recognizing the enormous potential of these research tools to solve some of today's biggest and most complex health problems. Computational epidemiology permits the examination and investigation of diseases and risk agents in plants, animals, and humans without jeopardizing lives or creating hazards. This relatively recent branch of science is being used by researchers to understand the overwhelming complexity of the 21st century's health problems. In light of this, computational models that study HIV/AIDS viral dynamics at the macro-population levels by examining the dynamics of HIV/AIDS among different racial

of 53%, with 8% classified as heavy alcohol consumers (Galvan et al., 2002).

These psychosocial problems, in turn, have been shown to influence high-risk sexual behaviors and HIV/AIDS transmission (Benotsch et al., 1999). However, study findings have been inconsistent about the relationship between psychosocial problems and unsafe sexual practices. Some studies have failed to find any relationship (Kalichman, 1999) while other research has demonstrated a negative relationship between psychosocial problems and high-risk sexual behaviors (Robins et al., 1994). The inconsistency in these research findings may be related to the fact that the specific link between HIV/AIDS and psychosocial problems is still not clearly defined. For example, depressive symptoms may lead patients to engage in high-risk behaviors [(e.g., injection drug use (IDU)] and subsequently lead to HIV infection (Angelino, 2002)]. On the other hand, rather than being direct the relationship between negative mood states and high-risk behaviors might be mediated by cognitive factors: being infected may affect mood states which in turn might affect an individual's ability to consistently make rational decisions about safe sex which may then at times lead to high-risk sexual behaviors and eventually lead to HIV/AIDS transmission (Binson et al., 1993). Thus, further research is need to gain a clear understanding of how psychosocial problems are likely to influence PLWHA and impact their ability to consistently make rational decisions is required to fully understand high-risk sexual behaviors among PLWHA.

In addition, depression is noted to be oftentimes associated with substance abuse (Saylors & Daliparthy, 2005) and other HIV/AIDS risky behaviors (Kelly et al., 1993). Substance abuse can cause cognitive impairment (Rippeth et al., 2004) which could also lead to depression (NIDA, 2006). Bing and colleagues (2001) assessed a national probability sample of nearly 3,000 PLWHA and found that more than one-third screened positive for clinical depression, the most common disorder identified. These researchers also indicated that half of the 3,000 PLWHA who participated in the study reported use of illicit drugs. Drug use was associated with screening positive for depression. The study showed also that 36% of HIV-infected individuals screened positive for depressive symptoms in the previous year (Bing et al., 2001). Another study found similar levels, as 35% of participants screened positive for depression (Pence, et al., 2007a). Additionally, studies have indicated higher rates of depression symptoms, ranging between 26% and 49%, in HIV-positive people compared with HIV-negative control groups (Boarts et al., 2006; Spiegel et al., 2003; Ickovic et al., 2001; Pence et al., 2006). The association between depression and substance abuse in predicting HIV/AIDS-risky behaviors has been examined and presented in this chapter.

#### **3. The relationship between substance abuse and risky sexual behaviors**

Substance abuse or other drug-taking activities, such as IDU, have long been recognized for their role in HIV/AIDS transmission (National Institute of Drug Abuse, 2006). Sexual intercourse while under the influence of drugs and/or alcohol can generally lower the use of condoms which can increase the risk of HIV/AIDS transmission (Saylors & Daliparthy, 2005) and quite possibly disease progression is more rapid (Zablotska et al., 2006).

PLWHA are more likely to abuse alcohol at some time during their lives (Abderhalden, 2007). A study by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institutes of Health, U.S. Department of Health and Human Services (2008) shows that 80% of people infected with the HIV in the U.S. drink alcohol; between 30% and 60% have been diagnosed with an alcohol-related abuse disorder. In the U.S., a one-month

These psychosocial problems, in turn, have been shown to influence high-risk sexual behaviors and HIV/AIDS transmission (Benotsch et al., 1999). However, study findings have been inconsistent about the relationship between psychosocial problems and unsafe sexual practices. Some studies have failed to find any relationship (Kalichman, 1999) while other research has demonstrated a negative relationship between psychosocial problems and high-risk sexual behaviors (Robins et al., 1994). The inconsistency in these research findings may be related to the fact that the specific link between HIV/AIDS and psychosocial problems is still not clearly defined. For example, depressive symptoms may lead patients to engage in high-risk behaviors [(e.g., injection drug use (IDU)] and subsequently lead to HIV infection (Angelino, 2002)]. On the other hand, rather than being direct the relationship between negative mood states and high-risk behaviors might be mediated by cognitive factors: being infected may affect mood states which in turn might affect an individual's ability to consistently make rational decisions about safe sex which may then at times lead to high-risk sexual behaviors and eventually lead to HIV/AIDS transmission (Binson et al., 1993). Thus, further research is need to gain a clear understanding of how psychosocial problems are likely to influence PLWHA and impact their ability to consistently make rational decisions is required to fully understand high-risk

In addition, depression is noted to be oftentimes associated with substance abuse (Saylors & Daliparthy, 2005) and other HIV/AIDS risky behaviors (Kelly et al., 1993). Substance abuse can cause cognitive impairment (Rippeth et al., 2004) which could also lead to depression (NIDA, 2006). Bing and colleagues (2001) assessed a national probability sample of nearly 3,000 PLWHA and found that more than one-third screened positive for clinical depression, the most common disorder identified. These researchers also indicated that half of the 3,000 PLWHA who participated in the study reported use of illicit drugs. Drug use was associated with screening positive for depression. The study showed also that 36% of HIV-infected individuals screened positive for depressive symptoms in the previous year (Bing et al., 2001). Another study found similar levels, as 35% of participants screened positive for depression (Pence, et al., 2007a). Additionally, studies have indicated higher rates of depression symptoms, ranging between 26% and 49%, in HIV-positive people compared with HIV-negative control groups (Boarts et al., 2006; Spiegel et al., 2003; Ickovic et al., 2001; Pence et al., 2006). The association between depression and substance abuse in predicting

HIV/AIDS-risky behaviors has been examined and presented in this chapter.

**3. The relationship between substance abuse and risky sexual behaviors** 

2005) and quite possibly disease progression is more rapid (Zablotska et al., 2006).

Substance abuse or other drug-taking activities, such as IDU, have long been recognized for their role in HIV/AIDS transmission (National Institute of Drug Abuse, 2006). Sexual intercourse while under the influence of drugs and/or alcohol can generally lower the use of condoms which can increase the risk of HIV/AIDS transmission (Saylors & Daliparthy,

PLWHA are more likely to abuse alcohol at some time during their lives (Abderhalden, 2007). A study by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institutes of Health, U.S. Department of Health and Human Services (2008) shows that 80% of people infected with the HIV in the U.S. drink alcohol; between 30% and 60% have been diagnosed with an alcohol-related abuse disorder. In the U.S., a one-month

sexual behaviors among PLWHA.

national representative sample of current alcohol use among PLWHA showed a prevalence of 53%, with 8% classified as heavy alcohol consumers (Galvan et al., 2002).

Needles and syringes are the second most common route of HIV transmission in the U.S. [World Health Organization (WHO)/UNAIDS, 2004; WHO, 2005]. Each year more than 8,000 people are newly infected with HIV through the sharing of HIV-contaminated syringes and needles (CDC, 2005). Since the beginning of the HIV pandemic, the CDC (2005) estimates that IDU has directly and indirectly accounted for approximately one-third (36%) of AIDS cases in the U.S. Globally, approximately 10% of HIV infections are a direct result of transmission through IDU (Aceijas et al., 2004).

HIV/AIDS intervention studies that target risky behaviors in various groups have been conducted in an assortment of settings. A study in France, for example, found that the proportion of HIV-positive patients reporting sexual behavior at risk for HIV transmission increased from 5.1% in 1998 to 21.1% in 2001-2002 (Desquilbet, 2002). In addition it has been shown that risky sexual behaviors, including unprotected sex and multiple sexual partners, occur among PLWHA (Schiltz and Sandfort, 2000). For example, a study by Binson (1993) indicates that a considerable percentage of PLWHA (range of 10% to 60% depending on the specific sex acts) continue to engage in unprotected sexual behaviors that place others at risk for infection and place themselves at risk for contracting secondary STDs (e.g., syphilis) which may accelerate HIV infection (Lowry, 1994). In another study conducted between 1999 and 2001 in San Francisco, California, found that the proportion of MSM reporting to have had unprotected anal sex with two or more partners of unknown serostatus increased from 19% to 25% for HIV positive MSM, compared to an increase from 10% to 15% for HIVnegative MSM participants (Chen et al., 2002).

The reasons that underlie the correlation between substance abuse and high-risk behaviors among PLWHA have been described to include: decreased inhibitions and risk perception; belief that alcohol and other drugs enhance sexual arousal and performance; deliberate substance abuse as an excuse for high-risk behaviors; and the indirect association that bars (taverns) are common places to meet potential sexual partners. The mechanisms by which substance abuse influences risky behaviors are associated with situational factors, such as cognitive impairment, social modelling, or the fact that substance abuse and risk-taking behaviors often occur in the same social venues (Abderhalden, 2007).
