Recreational drug use and sexual behavior change in a cohort of homosexual men. The Multicenter AIDS Cohort Study (MACS).

The relationship between use of recreational drugs and high-risk (HIV-transmitting) homosexual behavior was examined in the Multicenter AIDS Cohort Study (MACS) population. Among the 3916 men who completed both the baseline (1984) and first 6-month follow-up evaluations and were sexually active during the 6 months prior to enrollment, self-reported use of each of 10 classes of recreational drugs in conjunction with sexual activity was analyzed for both cross-sectional and prospective relationships with pattern of sexual behavior using a four-level sexual risk behavior index. At baseline, the proportion of men in the highest risk category (unprotected anal exposures with multiple partners) increased from 36 to 85% when men not using any drugs to men using three or more drugs plus volatile nitrites were examined. In multivariate logistical analyses, volatile nitrite use was significantly associated with failure to maintain or attain lower sexual risk levels after controlling for the effects of age, educational level and numbers of high-risk partners. These results suggest that volatile nitrite use may play an important role in the association between recreational drug use and high-risk sexual behavior among homosexual/bisexual men.

Relapse in sexual behavior among homosexual men: a 2-year follow-up from the Chicago MACS/CCS.

Serial biannual cross-sectional assessments of HIV sexual risk indicated a consistent increase in safer sexual practices among homosexual men participating in the Chicago-Multicenter AIDS Cohort Study (MACS)/Coping and Change Study (CCS) in 1986-1988. Safer sexual practices were achieved by avoidance of anal sex and less often by consistent use of condoms. Longitudinal patterns of variability in individual behavior were also assessed. After 1 year of follow-up, 53% of the participants maintained safer practices in receptive anal sex, 6% maintained unsafe practices, while 31% relapsed at least once. After 2 years, 45% maintained safer practices, 3% maintained unsafe practices and 47% relapsed at least once. Similar trends were observed in insertive anal sex.

Sexual behavior before AIDS: the hepatitis B studies of homosexual and bisexual men.

Data on sexual practices, collected during studies of hepatitis B virus (HBV) infection in 1978 and 1979, were analyzed for 4910 homosexual and bisexual men from Chicago, Denver, Los Angeles, San Francisco, and St Louis. Data on sexual practices in 1978 showed that white participants had larger numbers of non-steady male sexual partners and engaged in oral-genital activities more frequently but were equally likely to engage in anal intercourse as black and Hispanic participants. San Francisco participants had more non-steady sex partners and were more likely to engage in receptive anal intercourse with non-steady partners than participants from all other sites. Analysis of data on 606 HBV-antibody-negative men interviewed on three occasions in 1978 and 1979 showed no changes in risk indices for insertive and receptive anal intercourse between these years, except in San Francisco where significant declines occurred in insertive anal intercourse and receptive anal intercourse without ejacultion in a small, highly select group of participants.

Lithium-drug interactions altering the intracellular lithium level: an in vitro study.

An in vitro incubation system utilizing a bicarbonate-CO2 buffer system accurately predicts the in vivo red cell:plasma lithium ratio (LR). Piperazine phenothiazines produced the most marked elevations of intracellular lithium, doubling the LR when added to the system at 3 X 10(-5) M. The aminoalkyl phenothiazines and thioxanthenes were somewhat less active, while the non-phenothiazine antipsychotics, such as loxapine, haloperidol and molindone, produced only minor increases in the LR. Tricyclic antidepressants produced a 20-30% increase, while other types of antidepressants, the major neurotransmitters and their metabolites, hormones, benzodiazepines and diuretics did not show any activity. Of the antihypertensives studied, only hydralazine had an effect on the LR. The effect of fluphenazine on the intracellular lithium level was paralleled by an increase in intracellular sodium and was blocked by dipyridamole. Several important lithium-drug interactions may contribute to an increased LR and suggest caution in the interpretation of studies of the relationship between the LR and clinical aspects of the affective disorders.

Ion transport and adrenergic function in major affective disorder.

Altered functional levels of norepinephrine (NE) have been implicated in the etiology of affective disorders. Abnormalities of membrane ion transport have been postulated to underlie such neurotransmitter imbalances. To evaluate the role of these systems in the pathophysiology of specific affective syndromes, we have examined the NE metabolite MHPG and ion transport function in a cross-section of affective patients in different mood states. Analysis of those data reveals that plasma MHPG levels are dependent on mood state, with bipolar patients in the manic phase having significant elevations of this metabolite. In contrast, the red cell: plasma lithium ratio (LR) was independent of mood state and significantly elevated in a group of bipolar patients.

Mixture distributions in psychiatric research.

This paper describes the application of Gaussian mixture distributions to biological marker research in psychiatry. Mixtures of univariate and multivariate normal distributions can be used to determine if diagnostically similar psychiatric patients belong to biologically distinct subpopulations. The resulting biological subtypes may be important in understanding the etiology of psychiatric disorders. The general model and estimation procedure are described (EM algorithm; Dempster, Laird and Rubin 1977). The method is illustrated using two examples of biological data: (1) red cell membranes and monoamine oxidase activity data in normal individuals having no family history of psychiatric illness, the first-degree relatives of bipolar depressed patients and a heterogeneous patient population; and (2) smooth pursuit eye movements that classify relatives of schizophrenics, nonschizophrenics and normal controls into biologically distinct populations.

A heritable disorder of lithium transport in erythrocytes of a subpopulation of manic-depressive patients.

The in vivo RBC/plasma Li+ ratio is determined by the equilibrium between Li+ influx (ouabain-sensitive Na+-K+ pump and ouabain-insensitive leakage pathways) and Li+ efflux (phloretin-sensitive Li+-Na+ counterflow). A study of RBC Li+ transport via these pathways showed that a deficiency of Li+-Na+ counterflow was responsible for the high in vivo ratio (1:1) observed in a manic patient. This defect was related to an alteration in the membrane Na+ exchange system and was under genetic control. The level of counterflow before lithium therapy was an excellent predictor (r = .88) of the in vivo Li+ ratio and was deficient in approximately one-fourth of manic-depressive patients but not in controls, schizophrenics, or unipolar depressed patients.

HIV-related symptoms and psychological functioning in a cohort of homosexual men.

The authors administered the Center for Epidemiological Studies Depression (CES-D) Scale to 4,954 homosexual men in the Multicenter AIDS Cohort Study. HIV antibody status at enrollment was a less important predictor of psychological distress than were reported physical symptoms. Multivariate analysis showed an association between a high score on each CES-D Scale component and the number of self-reported possible AIDS- or HIV-related symptoms, perceived lymphadenopathy, and absence of "someone to talk to about serious problems." This relationship between self-reported physical symptoms and psychological distress suggests a possible etiologic relationship between perceived AIDS risk and psychological symptoms in men at risk of AIDS.

Biologic markers and antidepressant response.

The use of biologic markers to predict antidepressant treatment response may lead to more rational selection of specific drugs for individual patients. Several biologic markers being developed as potential predictors of antidepressant treatment response are reviewed. Although research in this area is primarily concerned with predicting response to drug treatment, it may also prove useful in predicting which depressed patients may respond best to psychological treatments or combinations of biologic and psychologic treatments.

The effect of alcoholism on membrane lithium transport.

Red cell lithium efflux rates in major affective disorder and alcoholic patient groups were studied. Current alcoholism was associated with significant elevation of lithium transport in white but not black subjects. This effect of alcoholism on the characteristics of membrane ion transport was independent of the blood pressure elevating effects of alcoholism and the diagnosis of major affective disorder. A model to explain the mechanism of this race-specific membrane effect of alcoholism is proposed and discussed.

Impact of combination therapies on HIV risk perceptions and sexual risk among HIV-positive and HIV-negative gay and bisexual men.

The availability of improved HIV treatments may prompt reduced concern about HIV and sexual risk. Gay and bisexual men (N = 554, 17% HIV-positive) completed measures of treatment attitudes, sexual risk, and assumptions regarding the infectiousness of sexual partners. A substantial minority reported reduced HIV concern related to treatment advances. Reduced HIV concern was an independent predictor of sexual risk, particularly among HIV-positive men. In response to hypothetical scenarios describing sex with an HIV-positive partner, participants rated the risk of unprotected sex to be lower if the partner was taking combination treatments and had an undetectable viral load, relative to scenarios with a seropositive partner not taking combination treatments. Prevention efforts must address attitudinal shifts prompted by recent treatment successes, stressing the continued importance of safer sex, and that an undetectable viral load does not eliminate infection risks.

Substance abuse and HIV infection.

This article reviews what is known about the relationships between recreational psychoactive substance use and HIV infection and sexual behaviors that can transmit HIV. The focus of this article is on nonparenterally used recreational substances and their relationship to HIV transmission behaviors, specifically high-risk sexual behaviors of one of the largest groups of persons at risk for infection--self-identified gay and bisexual men. Published and unpublished studies in this area are reviewed in terms of a hierarchy of epidemiologic evidence that ranges from global associations between substance use and high-risk sexual behaviors to prospective studies of substance use in the context of sexual encounters and incident rates of HIV infection. This article also discusses the secondary community impact of these associations and their intervention implications.

Preservation of human erythrocytes for sodium-dependent lithium efflux rate measurements.

Measurement of red blood cell ion transport levels have become increasingly important as biological markers in psychiatric research. A major drawback to large-scale collaborative studies of red blood cell lithium transport rates has been the requirements of fresh cells and a transport research laboratory for performance of the assays. We have developed a method for the preservation of human red blood cells for up to five days with retention of lithium efflux characteristics. This method should find wide-scale application in collaborative studies of this marker in major affective disorders, in genetic studies of families living in diverse geographic locales, and in collaborative studies utilizing a centralized transport assay laboratory.

Effects of HIV infection, perceived health and clinical status on a cohort at risk for AIDS.

Data from a general population sample of 621 healthy homosexual men are used to evaluate the social and emotional effects of HIV antibody status, clinical signs detected by medical examination, and subjectively perceived symptoms. Participants are unaware of their serologic status at the time of data collection, thus allowing the effects of the virus to be separated from reactions to the knowledge of serologic status. The data show that seropositivity for HIV is not associated with elevated levels of social or emotional impairment. Clinical signs lead to impairment in baseline data, but these effects do not persist at a second wave. This weakening suggests that the effects are mediated by psychological pathways rather than biologic ones. This suspicion is confirmed in further analyses, which show that the effects of clinical signs are mediated by subjectively perceived symptoms. These results show that neither social nor emotional impairment is likely to be a prodromal sign of HIV infection in otherwise healthy homosexual men. The substantial levels of distress found among these men is more directly influenced by psychological determinants than biologic ones. This suggests that physicians should be aware of the psychological toll imposed on gay men who develop health problems in the current atmosphere of uncertainty regarding risk of AIDS.

Predictors of sexual behavior change among men requesting their HIV-1 antibody status: the Chicago MACS/CCS cohort of homosexual/bisexual men, 1985-1986.

It has been proposed that human immunodeficiency virus (HIV) antibody testing and counseling are effective means of altering sexual behavior among individuals at risk of HIV infection and transmission. However, the evidence supporting this hypothesis is inconclusive. This study examines the factors associated with sexual behavior change among a group of participants in the Chicago MACS/Coping and Change Study (CMACS/CCS) who requested their HIV antibody status when they were first given the opportunity, between 1985 and 1986. A set of demographic and psychosocial predictors were tested in association with 4 possible outcome patterns of sexual behavior change during the time of antibody status disclosure. For comparative purposes, a randomly selected sample of men who did not request disclosure of their HIV antibody status was analyzed. The results revealed that, among the 177 individuals who requested disclosure, the group experiencing an adverse sexual behavior change (i.e., from low risk before disclosure to high risk after disclosure) reported, before disclosure, the highest level of mental distress and denial-fatalism coping strategies and had the lowest levels of social support compared with other groups being analyzed. The psychosocial predictor most strongly associated with adverse sexual behavior change appears to be the use of denial-fatalism coping. Such an association was not found among the nondisclosed comparison group. These results suggest that a subgroup of at-risk, well-educated, white men, with overall high knowledge of HIV transmission, may not benefit from current HIV counseling and testing. Such men at risk for adverse behavioral outcomes might be identified in advance of HIV-1 antibody testing by their psychosocial profile, and thus appropriate counseling resources could be targeted to them.

Predictors of relapse in sexual practices among homosexual men.

Selected sociodemographic, psychosocial, and behavioral variables were used to predict maintenance or relapse in sexual practices over a 1-year interval in a cohort of homosexual men in Chicago. Univariate analyses and multivariate logistic regression were used to define predictive models for safer practices separately for insertive and receptive and sex. Demographic and psychosocial variables were not associated with subsequent relapse. Neither was HIV serostatus. Using more rigorous multiple logistic regression, only monogamous relationships, less peer support, and less assertiveness in negotiating safer sex appeared to predict relapse to less safe practices. The importance of interpersonal variables and social norms for future interventions among homosexual men is discussed.

Who hasn't heard about AIDS?

This article analyzes who among the general population has not heard about AIDS despite intensive educational programs and widespread media attention about the syndrome. The data are drawn from a survey of the general public's knowledge, attitudes, and behavior toward AIDS in May-July, 1987 to establish a baseline for future educational interventions and to identify groups in need of special educational efforts. A total of 1540 interviews were conducted in Chicago and the surrounding six-county metropolitan area with adults between the ages of 18 and 60 in a two-stage cluster sample designed to compare blacks, whites, and Hispanics. Of the 1540 respondents, 49 (3.2%) had never heard of AIDS. Contingency table and logistic regression analyses indicated that lower educational levels and being Hispanic or Asian predict not having heard about AIDS. The results suggest the need for programs and intervention strategies that consider the special characteristics of these populations.

The Health Belief Model in understanding compliance with preventive recommendations for AIDS: how useful?

The Health Belief Model (HBM) has been applied to a variety of health conditions: most are less threatening and require less complex responses than those arising in the case of AIDS. The utility of the HBM in understanding preventive behaviors in AIDS is examined in a cohort of homosexual men at two different time points. Longitudinal analyses estimated the relationship of indices assessing susceptibility, severity, benefits, and barriers, as well as sociodemographic factors, to sexual behavior across the next 18 months. Analyses further defined these associations in specific subgroups of participants, such as those initially at lower or higher risk. In general, measures of severity and socioeconomic advantage had the most consistently beneficial effect on various measures of behavior. Little or no beneficial effect was observed for other components of the HBM, notably a measure of perceived susceptibility. These analyses suggest that the special features of AIDS may require development of more adequate theoretical frameworks.

Differentiating DST suppressors from nonsuppressors: a discriminant function analysis of clinical symptoms.

Ninety-seven patients who presented with depressive complaints were studied in an attempt to cross-validate a statistical model that uses items from the Hamilton Rating Scale for Depression (HRSD) to differentiate dexamethasone suppressors from nonsuppressors. Two split-sample discriminant function analyses (DFA) of data from this sample showed little agreement with either the original model or with each other. Accuracy of classification was acceptable for the derivation samples but was no better than chance for the validation samples. No single HRSD item was identified by all three DFAs as distinguishing between groups. The HRSD does not appear to be a reliable instrument for clinically distinguishing dexamethasone suppressors from nonsuppressors.

Substance use, HIV, and gay men.

AIDS: Recreational drug use is linked to infectious disease transmission among gay men. A review of the literature on substance use and sexual behavior divided the research into three categories: studies that relate sexual behavior to global measures of drug use; studies that look within groups of gay men at drug use behavior in the sexual context; and studies that look at sexual episodes among individual cases to determine whether the use of specific drugs lead to specific sexual activities. The evidence for a direct association between substance use and increased risk of HIV infection among susceptible gay men is incontrovertible. Simple associational models demonstrate the ways in which the pairing of sex and drug use create a learned association between these activities. The drug-sex relationship may also be mediated by personality characteristics, such as sensation-seeking. Interventions targeting gay men must combine community interventions and individual or small group intervention approaches.^ieng