Alcohol Misuse, HIV Risk and Screening Uptake in ED Patients
Alcohol Misuse, HIV Risk and Screening Uptake in ED Patients
Previous studies have noted a high prevalence of reported alcohol misuse, at-risk drinking and sexual risk for HIV among US ED patients. Among participants in this study, too, there was a high prevalence of reported alcohol misuse and sexual risk for HIV. Our study results were consistent with our hypothesis that there was a relationship between reported alcohol misuse and reported sexual risk for HIV among participants who consume alcohol. However, we did not observe a relationship between reported alcohol misuse and HIV screening uptake; reported sexual risk for HIV and HIV screening uptake; and HIV screening uptake and an intersection of sexual risk for HIV (sex while intoxicated, regret ever having had sex while intoxicated and unsure if ever had sex while intoxicated) and alcohol misuse. There were some initial suggestions of a relationship between HIV screening uptake and the intersection of sexual risk for HIV and alcohol misuse, but demographic characteristics superseded this relationship.
These results raise questions as to why some relationships were found and not others. We observed a disconnection between sexual risk behaviors, alcohol misuse and HIV screening uptake. This finding suggests that participants in our study were unable to make crucial connections between their alcohol misuse and their sexual risk behaviors and translate this connection into a need for HIV testing. Based upon these results, we believe there is a need to reevaluate current alcohol misuse and HIV prevention and screening efforts that are being utilized in EDs. This disconnection among self-perceived, reported and actual risk and uptake of HIV screening has been observed in other studies. For example, in a cross-sectional study conducted by MacKeller et al. in six US cities, 5,649 male participants who have sex with men were interviewed, were provided HIV sexual risk counseling and were offered HIV screening. Of these participants, 77% of those that tested positive for HIV were unaware they were infected, 59% perceived themselves as low-risk for being infected with HIV and 44% perceived themselves as low-risk for ever becoming infected.
The need for effective interventions for the co-occurring problems of alcohol misuse and sexual risk for HIV in the ED is strongly suggested given the high-risk alcohol consumption and sexually risky behaviors reported by those in this study. A number of studies have demonstrated support for brief alcohol interventions in the ED. However, we know of no published research examining sexual risk reduction interventions among ED patients. Furthermore, we know of no published research examining if a combination of brief alcohol interventions and HIV risk interventions is effective within this population in reducing sexual risk and increasing uptake of HIV screening. Support for this approach has been voiced by researchers in non-ED settings. Volkow et al. advocate that integrating substance abuse treatment into HIV prevention may improve public health outcomes (e.g. decreasing HIV incidence) and aid in reducing HIV transmission among injection and non-injection substance users. In a randomized trial by Kalichman et al., 313 participants were randomly assigned to a three-hour HIV-alcohol risk-reduction skills intervention or a single one-hour HIV-alcohol education control group. There was an increase of 100% usage of condoms or absence of sex in the lighter drinking group (77% vs. 43%; p < 0.01) but not in the heavier drinking group (55% vs. 59%, p < 0.05).
More research is needed to understand the connection between alcohol misuse, sexual risk for HIV and HIV screening uptake in the ED setting. Furthermore, patients who report high-risk behaviors, such as those identified in this study, for the acquisition of HIV may need help in recognizing these connections, reducing their risk behaviors, and accepting HIV testing. Further evaluations of the applicability and efficacy of integrated alcohol misuse and HIV sexual risk interventions within acute settings, such as EDs, is needed to determine effectiveness for this population. Intervention content regarding sexual risk behaviors in relation to alcohol misuse for ED patients should be evaluated and tested to reduce sexual risk and alcohol misuse and increase HIV screening uptake.
This study had a number of limitations. Self-report data regarding alcohol consumption and sexual risk for HIV may be inaccurate. Study participants may have underestimated or not recalled information regarding their alcohol consumption and HIV testing history. However, self-report of alcohol consumption and sexual behavior can be a reasonable method of obtaining these data. Also, we did not collect data on whether or not the participant's ED visit was related to their alcohol use. We do provide information regarding their level of at-risk drinking. Social desirability factors may have influenced some patients in their responses to reasons for accepting or declining screening, rather than any perception of their risk. Furthermore, it is unclear whether acceptance of screening based on an opt-out approach in the ED would be similar for participants who were excluded from the study. However, an opt-out approach may not be appropriate for patients who are unable to provide study consent. The HIV Sexual Risk Questionnaire has not been validated as a predictor of acquisition of HIV. As such, the true relationship between reported risk and HIV acquisition cannot be determined by this study. In addition, only 15.2% of women and 29.3% of men reported having unprotected sex with a casual partner (with or without an exchange or main partner), and most participants reported only sex with a main sexual partner. As such, the majority of participants could potentially be considered at lower risk for acquiring HIV, which might have appropriately influenced the uptake of testing. The small sample size may have produced limitations in identifying differences when they do exist. The study outcomes may not be appropriate for other EDs with different demographic characteristics, even though we attempted to obtain a representative sample by randomly selecting dates, shifts and participants. Of course, a failure to demonstrate relationships, should they exist, could have been related to the nature of the questions asked, their format, and the interpretation of the questions by the participants. Alternative questions, topics, and approaches could yield different results.
Discussion
Previous studies have noted a high prevalence of reported alcohol misuse, at-risk drinking and sexual risk for HIV among US ED patients. Among participants in this study, too, there was a high prevalence of reported alcohol misuse and sexual risk for HIV. Our study results were consistent with our hypothesis that there was a relationship between reported alcohol misuse and reported sexual risk for HIV among participants who consume alcohol. However, we did not observe a relationship between reported alcohol misuse and HIV screening uptake; reported sexual risk for HIV and HIV screening uptake; and HIV screening uptake and an intersection of sexual risk for HIV (sex while intoxicated, regret ever having had sex while intoxicated and unsure if ever had sex while intoxicated) and alcohol misuse. There were some initial suggestions of a relationship between HIV screening uptake and the intersection of sexual risk for HIV and alcohol misuse, but demographic characteristics superseded this relationship.
These results raise questions as to why some relationships were found and not others. We observed a disconnection between sexual risk behaviors, alcohol misuse and HIV screening uptake. This finding suggests that participants in our study were unable to make crucial connections between their alcohol misuse and their sexual risk behaviors and translate this connection into a need for HIV testing. Based upon these results, we believe there is a need to reevaluate current alcohol misuse and HIV prevention and screening efforts that are being utilized in EDs. This disconnection among self-perceived, reported and actual risk and uptake of HIV screening has been observed in other studies. For example, in a cross-sectional study conducted by MacKeller et al. in six US cities, 5,649 male participants who have sex with men were interviewed, were provided HIV sexual risk counseling and were offered HIV screening. Of these participants, 77% of those that tested positive for HIV were unaware they were infected, 59% perceived themselves as low-risk for being infected with HIV and 44% perceived themselves as low-risk for ever becoming infected.
The need for effective interventions for the co-occurring problems of alcohol misuse and sexual risk for HIV in the ED is strongly suggested given the high-risk alcohol consumption and sexually risky behaviors reported by those in this study. A number of studies have demonstrated support for brief alcohol interventions in the ED. However, we know of no published research examining sexual risk reduction interventions among ED patients. Furthermore, we know of no published research examining if a combination of brief alcohol interventions and HIV risk interventions is effective within this population in reducing sexual risk and increasing uptake of HIV screening. Support for this approach has been voiced by researchers in non-ED settings. Volkow et al. advocate that integrating substance abuse treatment into HIV prevention may improve public health outcomes (e.g. decreasing HIV incidence) and aid in reducing HIV transmission among injection and non-injection substance users. In a randomized trial by Kalichman et al., 313 participants were randomly assigned to a three-hour HIV-alcohol risk-reduction skills intervention or a single one-hour HIV-alcohol education control group. There was an increase of 100% usage of condoms or absence of sex in the lighter drinking group (77% vs. 43%; p < 0.01) but not in the heavier drinking group (55% vs. 59%, p < 0.05).
More research is needed to understand the connection between alcohol misuse, sexual risk for HIV and HIV screening uptake in the ED setting. Furthermore, patients who report high-risk behaviors, such as those identified in this study, for the acquisition of HIV may need help in recognizing these connections, reducing their risk behaviors, and accepting HIV testing. Further evaluations of the applicability and efficacy of integrated alcohol misuse and HIV sexual risk interventions within acute settings, such as EDs, is needed to determine effectiveness for this population. Intervention content regarding sexual risk behaviors in relation to alcohol misuse for ED patients should be evaluated and tested to reduce sexual risk and alcohol misuse and increase HIV screening uptake.
Limitations
This study had a number of limitations. Self-report data regarding alcohol consumption and sexual risk for HIV may be inaccurate. Study participants may have underestimated or not recalled information regarding their alcohol consumption and HIV testing history. However, self-report of alcohol consumption and sexual behavior can be a reasonable method of obtaining these data. Also, we did not collect data on whether or not the participant's ED visit was related to their alcohol use. We do provide information regarding their level of at-risk drinking. Social desirability factors may have influenced some patients in their responses to reasons for accepting or declining screening, rather than any perception of their risk. Furthermore, it is unclear whether acceptance of screening based on an opt-out approach in the ED would be similar for participants who were excluded from the study. However, an opt-out approach may not be appropriate for patients who are unable to provide study consent. The HIV Sexual Risk Questionnaire has not been validated as a predictor of acquisition of HIV. As such, the true relationship between reported risk and HIV acquisition cannot be determined by this study. In addition, only 15.2% of women and 29.3% of men reported having unprotected sex with a casual partner (with or without an exchange or main partner), and most participants reported only sex with a main sexual partner. As such, the majority of participants could potentially be considered at lower risk for acquiring HIV, which might have appropriately influenced the uptake of testing. The small sample size may have produced limitations in identifying differences when they do exist. The study outcomes may not be appropriate for other EDs with different demographic characteristics, even though we attempted to obtain a representative sample by randomly selecting dates, shifts and participants. Of course, a failure to demonstrate relationships, should they exist, could have been related to the nature of the questions asked, their format, and the interpretation of the questions by the participants. Alternative questions, topics, and approaches could yield different results.
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