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Alcohol tied to intentions for condom-free sex in gay men with HIV.

Drinking alcohol roused the intention to have sex without condoms in a novel study involving gay and bisexual men with or without HIV infection. (1) This clever study appears to be the first that randomly assigned HIV-positive or negative men to drink alcohol or nonalcoholic drinks, then to watch a sexually stimulating video or a nonsexual video, then to say whether they felt like having anal sex with or without a condom.

Sex without condoms between gay or bisexual men plays a big role in sustaining the HIV epidemic in the United States, Canada, and countries with similar HIV epidemics. Most gay or bisexual men keep having sex after they become infected with HIV, and many do not use condoms during sex. (2)

Much research has explored how drinking alcohol may be linked to the risk of having sex without condoms. (3) But this research usually involved a one-time look at the study population and relied on questionnaires to establish general alcohol use patterns and condomless sex in the past. Although some research has used controlled experiments to more directly test whether alcohol is linked to intentions to have sex without condoms, (4,5) none of the these experiments involved people who were living with HIV.

Researchers in Canada conducted this study to create such an experiment.

How the study worked. The study involved 282 HIV-positive or HIV-negative gay and bisexual men in care at a Toronto clinic that sees gay and bisexual men, including men with HIV. Researchers randomly assigned each man to drink (1) enough alcohol to reach a target blood alcohol level of 0.080%, (2) fake alcohol, or (3) water. (People with a blood alcohol level of 0.080% or higher can be charged with driving under the influence of alcohol.) Researchers also randomly assigned each man to watch either (1) video clips designed to be sexually arousing, or (2) video clips that would not be sexually arousing. After men watched these videos, researchers asked them whether they would have condom-free anal sex with partners shown in photos.

The alcohol drink was a 1-to-3 mix of vodka and tonic. The fake alcohol drink was a 1-to-3 mix of flat tonic water plus regular tonic, with a small amount of vodka on top and vodka rubbed on the rim of the glass. Half of the men got alcohol, one quarter got fake alcohol, and one quarter got water.

Men in the study had to be at least 19 years old (legal drinking age in Toronto). They had to report having anal sex with a man in the past 6 months. They had to be a social drinker but could not have an alcohol problem or problems with other drugs. No man could have a medical condition that made drinking dangerous.

The experiment took place in a special barroom lab. Men finished their drinks in 15 minutes, followed by a 13-minute absorption period. Then men used a touchscreen computer to view either arousing or nonarousing videos and to view photos of 18 physically attractive or unattractive potential "first-time partners" plus text indicating whether the partner had HIV and the partner's condom preference.

The researchers used standard statistical methods to determine whether drinking alcohol (versus fake alcohol or water) resulted in the intention to have condom-free sex with the partners seen in the pictures. This analysis also determined whether being HIV-positive versus HIV-negative affected reactions to drinking.

What the study found. The study group included 141 men with HIV and 141 HIV-negative men. All men were gay or bisexual. Their age averaged 42.6 years and ranged from 20 to 69. Nearly three quarters of men (72%) were white, and there were small proportions of mixed-race men (11%), Latin Americans (7%), and blacks (4%). Most men (72%) had a college degree, and 68% had a job. The group drank an average 9.9 alcoholic drinks weekly, and 89% drank alcohol before or during sex. Among men with HIV infection, 85% were taking antiretroviral therapy * and 82% had an undetectable viral load.

Average peak blood alcohol level was 0.086%, close to the target of 0.080%. Fake alcohol and water had the same limited impact on intention to have condom-free anal sex, so the researchers combined those results.

Intention to have condom-free sex was significantly greater in men who drank alcohol than in those who did not (risk intention 1.86 versus 1.61, P = 0.002; providers see note 6 for more details). In other words, compared with men who did not drink alcohol, men who drank alcohol were more likely to express an intention for condom-free anal sex. The impact of alcohol on condomless sex intentions was similar in men with versus without HIV infection.

What the findings mean for you. This study is the first controlled experiment to show that drinking alcohol can directly increase the intention to have sex without condoms in gay and bisexual men with HIV or without HIV. Prior research found a link between drinking and condomless sex intentions among people who were not infected with HIV. (4,5) The new study extends that finding to show that drinking alcohol has a similar stimulating effect on sex without condoms in men with HIV.

This finding is important because condoms are a reliable way to prevent an HIV-positive partner from passing HIV to a negative sex partner. Because gay and bisexual men account for most new HIV infections in countries like the United States and Canada, consistent condom use is an important step in limiting the HIV epidemic in those countries. Condoms are also important for people with or without HIV because they can protect sex partners from sharing other viruses and bacteria that can cause serious diseases. For example, hepatitis viruses and cancer-causing human papillomaviruses can pass more easily between sex partners not using condoms.

Depending on the group studied, anywhere from 8% to 42% of people with HIV have an alcohol problem. (7) In the United States, groups with the highest rates of both HIV and alcohol abuse are gay or bisexual men, racial or ethnic minorities, people who inject drugs, sex workers, and people with low income. (7) In a study of gay/bisexual men in San Francisco, two thirds reported binge drinking in the past year. (8)

Heavy alcohol drinking can cause or contribute to heart disease, stroke, liver fibrosis or cirrhosis, weak bones, cancers of the liver, breast, mouth, throat, and esophagus, and other diseases and conditions (Figure 1). (9) In people with HIV, drinking too much alcohol is linked to worsening HIV disease and worse antiretroviral pill-taking habits.

If you have a drinking problem, talk to your HIV provider or to a counselor at an HIV support center about making a plan to quit or control your drinking. The US National Institute on Alcohol Abuse and Alcoholism has a useful online tool to find quality treatment for alcohol abuse somewhere near you. Click on the link at reference 10 below.


(1.) Shuper PA, Joharchi N, Monti PM, Loutfy M, Rehm J. Acute alcohol consumption directly increases HIV transmission risk: a randomized controlled experiment. J Acquir Immune Defic Syndr. 2017;76:493-500.

(2.) Centers for Disease Control and Prevention (CDC). High-risk sexual behavior by HIV-positive men who have sex with men--16 sites, United States, 2000-2002. MMWR. 2004;53:891-894.

(3.) Shuper PA, Joharchi N, Irving H, et al. Alcohol as a correlate of unprotected sexual behavior among people living with HIV/AIDS: review and meta- analysis. AIDS Behav. 2009;13:1021-1036.

(4.) Rehm J, Shield KD, Joharchi N, Shuper PA. Alcohol consumption and the intention to engage in unprotected sex: systematic review and meta-analysis of experimental studies. Addiction. 2012;107:51-59.

(5.) Scott-Sheldon LA, Carey KB, Cunningham K, et al. Alcohol use predicts sexual decision-making: a systematic review and meta-analysis of the experimental literature. AIDS Behav. 2016;20(suppl 1):S19-S39.

(6.) Note for providers: The analysis used a general linear model based on a repeated-measures full-factorial analysis of variance. Drinking was dichotomized as alcohol versus nonalcohol (fake alcohol or water). The full factorial general linear model included (1) alcohol versus nonalcohol, (2) HIV-positive versus HIV-negative, and (3) sexual arousal versus nonarousal as between-subject variables. The model considered partner characteristics as within-subject factors.

(7.) Williams EC, Hahn JA, Saitz R, Bryant K, Lira MC, Samet JH. Alcohol use and human immunodeficiency virus (HIV) infection: current knowledge, implications, and future directions. Alcohol Clin Exp Res. 2016;40:2056-2072.

(8.) Santos GM, Jin H, Raymond HF. Pervasive heavy alcohol use and correlates of increasing levels of binge drinking among men who have sex with men, San Francisco, 2011. J Urban Health. 2015;92:687-700.

(9.) National Institute on Alcohol Abuse and Alcoholism. Alcohol's effects on the body,

(10.) National Institute on Alcohol Abuse and Alcoholism. NIAAA Alcohol Treatment Navigator.

* Words in boldface are explained in the Technical Word List at the end of this issue.

Caption: Figure 1. People with HIV infection run a high risk of heart disease, stroke, liver disease, low bone density, and certain cancers. These are only some of the problems that drinking too much alcohol can cause or worsen. (Illustrations from Servier PowerPoint Image Bank, http://
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Title Annotation:ARTICLE 10
Publication:HIV Treatment: ALERTS!
Date:May 1, 2018
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