رفتارهای پرخطر اچ آی وی در معتادان مرد با و بدون اختلال شخصیت ضد اجتماعی

Abstract Antisocial personality disorder (ASP) is common in male substance abusers and may be associated with increased human immunodeficiency virus (HIV) risk behaviors. In this study, 91 male substance abusers were recruited from the community, and 42% met diagnostic criteria for ASP. Although ASP and non-ASP subjects demonstrated equivalent knowledge about HIV, subjects with ASP participated in more risky behaviors. On a lifetime measure of drug risk behaviors, ASP subjects reported higher rates of intravenous drug use (IVDU), frequency of needle-sharing, and number of equipment-sharing partners and lower rates of needle-cleaning. On a measure of past-month risk behaviors, ASP subjects reported higher rates of IVDU and lower rates of needle-cleaning. Subjects with ASP also reported greater participation in lifetime sexual risk behaviors, including number of sexual partners and frequency of anal sex. These findings suggest that clients entering substance abuse treatment programs should be screened for ASP, and clients identified with ASP should be provided risk-reduction interventions early in treatment.

Introduction In 1998, the Center for Disease Control and Prevention reported over 36,000 new acquired immunodeficiency syndrome (AIDS) cases were identified in adult males; 21% of cases were intravenous drug users, and another 5% were homosexuals who also used intravenous drugs. Females comprised the remaining 11,000 new adult AIDS cases, and 29% resulted from heterosexual contact with a male intravenous drug user (Centers for Disease Control and Prevention, 1998). Thus, male substance abusers are at high risk for contracting and spreading HIV. The two primary modes of HIV transmission are intravenous drug use (IVDU) and unsafe sex behaviors. Rates of IVDU range from 32 to 47% among cocaine-abusing clients Booth 1995 and Compton et al. 1995 and are as high as 90% in heroin-abusing clients (e.g., Ball & Ross, 1991). Even alcohol-dependent clients engage in IVDU, with studies showing a history of IVDU among 37% of primary alcoholics (Avins et al., 1997; see Petry, 1999). Despite growing awareness of safe injection practices (Gibson et al., 1993), 15 to 40% of intravenous drug users report recent (past 30 days) risky needle practices, such as borrowing and lending of needles Darke et al. 1994 and Magura et al. 1989. Risky sexual behaviors are prevalent in substance abusers as well. For example, 72% of male substance abusers report multiple sex partners (Edlin et al., 1994) and only 11% report consistent condom use with casual sex partners (Magura et al., 1989). Over 20% of male substance abusers acknowledge trading sex for drugs or money (Booth, 1995), and 10% report that their last penetrative sexual experience was commercial sex (Watkins et al., 1993). Finally, up to 35% of male substance abusers participate in anal intercourse (Kim et al., 1993), with 7% stating they have had over 50 partners for homosexual anal intercourse (Edlin et al., 1994). Antisocial personality disorder (ASP) is a psychiatric condition that is common among substance abusers and may be associated with increased participation in HIV risk behaviors. Rates of ASP range from 30 to 44% in heroin-abusing populations Brooner et al. 1990 and Brooner et al. 1992, from 35 to 53% in cocaine-abusing populations Carroll et al. 1993 and Compton et al. 1995 and from 6 to 23% in alcohol-abusing populations Holdcraft et al. 1998 and Morgenstern et al. 1997. Rates of ASP are higher among male (26–50%) compared to female substance abusers (9–35%; Brooner et al. 1992 and Morgenstern et al. 1997). A growing body of evidence suggests that ASP may be a risk factor for engaging in behaviors that increase the likelihood of contracting and spreading HIV. Among a sample of 55 heroin-abusing clients, ASP was associated with increased needle risk behaviors, such as frequency of needle-sharing and number of needle-sharing partners (Gill et al., 1992). In cocaine abusers, ASP was associated with increased rates of IVDU and sharing of needles within the past 6 months (Compton et al., 1995). In a general sample of intravenous drug users, a diagnosis of ASP was associated with a greater likelihood of sharing injection equipment and a greater number of needle-sharing partners Brooner et al. 1990 and Brooner et al. 1993. ASP may be associated with increased sex risk behaviors as well. Compared to their non-ASP counterparts, both heroin and cocaine abusers with ASP reported more sex partners and participation in commercial sex Compton et al. 1995, Compton et al. 1998 and Gill et al. 1992. Thus, ASP seems to be associated with increased participation in both IVDU and sexual risk behavior. In the present study, we replicated and extended these findings by examining risk behaviors in a heterogeneous group of substance abusers, including individuals both in and not in treatment. We evaluated the prevalence of ASP in males with heroin, cocaine, or alcohol use disorders. We also compared participation in risky IVDU and sexual behaviors among substance abusers with and without ASP, utilizing both lifetime and recent rates of risk behaviors.

3. Results Table 1 shows demographic characteristics, drug use variables, and ASI scores for male substance abusers with and without ASP. The two groups differed in on their current primary substance of abuse, χ2(2) = 8.14, p < .05, and their lifetime history of cocaine and opioid abuse, χ2(1) = 6.61, p = .01, and χ2(1) = 5.59, p < .05, respectively. Urinalysis results also differed significantly between groups, χ2(1) = 4.08, p < .05, with ASP subjects more likely to test positive for opioids than non-ASP subjects. Although not statistically significant, trends toward differences between the groups were noted in regard to ethnicity, χ2(2) = 4.36, p = .113, legal income in the past year, t(89) = 1.75, p = .08, and ASI medical, employment, and psychiatric scores, t(89) = 1.62, 1.78, and 1.84, p < .11, respectively. Table 1. Demographics, drug use characteristics, and HIV risk behavior scores Variable Non-ASP male substance abusers ASP male substance abusers n 48 43 Age (years) 41.4 (8.7) 40.9 (8.4) Race (%) Caucasian 63 42 African American 29 40 Hispanic 8 19 Education (years) 12.6 (2.1) 12.1 (2.1) Marital status Married/remarried 23 19 Divorced/separated 44 33 Never married 33 49 Annual legal income ($) 9,921 (12,458) 6,034 (7,954) Addicition Severity Index subscale scores Medical 1.70 (2.88) 2.80 (3.55) Employment 5.53 (3.35) 6.70 (2.87) Alcohol 3.00 (2.20) 2.34 (2.07) Drug 1.06 (1.22) 1.40 (1.22) Legal 1.41 (2.28) 1.70 (2.13) Family/Social 1.91 (1.98) 2.22 (2.31) Psychiatric 1.94 (2.15) 2.85 (2.56) Breath and urinalysis results (% positive) Alcohol 2 7 Marijuana 17 14 Cocaine 29 33 Opioids* 8 24 For any drug 38 37 Current primary drug of abuse (%)* Alcohol 42 16 Cocaine 35 40 Heroin 23 44 Self-reported use in past 30 (days) Alcohol (to intoxication) 6.3 (8.5) 5.8 (9.7) Marijuana 1.6 (4.3) 2.1 (6.6) Cocaine 3.9 (7.4) 5.5 (8.0) Opioids 2.4 (6.9) 3.5 (8.9) Subjects with lifetime abuse (%) Alcohol 87 77 Cocaine* 56 81 Opioids* 31 56 In treatment for substance abuse (%) 50 51 Heterosexual (%) 96 98 Note: Values are means and standard deviations, unless otherwise specified. HIV = human immunodeficiency virus; ASP = antisocial personality disorder. * Significantly different between groups (p < .05). Table options The top panel of Fig. 1 shows lifetime and past-month composite scores associated with drug risk behaviors among subjects with and without ASP. Both lifetime and past-month scores differed significantly between the groups, U = 757 and 837, p < .01, respectively, with ASP subjects reporting more frequent participation in risky drug use behaviors. Top panel: Mean lifetime and past-month composite scores on the the HIV Risk ... Fig. 1. Top panel: Mean lifetime and past-month composite scores on the the HIV Risk Behavior Scale (HRBS) drug risk behavior scale for subjects with and without antisocial social behavior (ASP). Because scores were non-normally distributed, nonparametric tests were used to evaluate differences between groups, and the asterisks indicate values that were significantly different between the groups. (Median values are not shown because they equaled 0 for both groups.) See text for further details. Bottom panel: Mean lifetime and past-month composite scores on the HRBS sex risk behavior scale for subjects with and without ASP Figure options The bottom panel of Fig. 1 shows this same information for sexual risk behaviors. Lifetime composite sex risk behaviors differed significantly between the groups, U = 773, p < .05, with ASP subjects reporting greater participation in sexual risk behaviors than non-ASP subjects. No differences were found between the groups for sex risk composite scores in the past 30 days. Table 2 shows responses on the individual drug risk behavior questions of the HRBS for the two groups of subjects. For lifetime measures, the frequency of IVDU differed significantly between the two groups. Specifically, 46% of subjects with ASP reported a lifetime history of IVDU compared with 21% of subjects without ASP, and 35% of subjects with ASP reported a lifetime history of daily IVDU compared with only 13% of non-ASP subjects. Statistically significant differences between the groups were also noted in the rates of lifetime risky needle-sharing and cleaning practices. For example, ASP subjects were more likely to use needles after others had used them and to allow others to use needles after them. The two groups also differed significantly in terms of frequency of needle-cleaning in their lifetime, and subjects with ASP tended to report less frequent lifetime use of bleach as a way to clean needles. Table 2. Percentage of subjects reporting various drug use risk behaviors Non-ASP male substance abusers (%) ASP male substance abusers (%) Mann–Whitney U-test p Items and responses LT/MO LT/MO LT/MO LT/MO How often have you used drugs intravenously? (n = 48) (n = 43) 752/835 .007/.004 (0) Never/Never 79/98 54/79 (1) 1–2 times/Once 2/0 2/2 (2) 3–10 times/More than once but <30 times 4/2 7/5 (3) >10 times, but never greater than once per month/Once a day 0/0 0/5 (4) More than once per month, but never daily/2–3 times a day 2/0 2/0 (5) Regularly or daily for any given time/>3 times a day 13/0 35/9 How many times have you used a needle after someone else? 835/984 0.25/.133 (0) Never 90/100 70/95 (1) Once 0/0 0/5 (2) Twice 0/0 7/0 (3) 3–5 times 0/0 7/0 (4) 6–10 times 4/0 0/0 (5) >10 times 6/0 16/0 How many different people have used a needle before you? 862/984 .047/.133 (0) None 90/100 72/95 (1) One 0/0 7/2 (2) Two 0/0 5/2 (3) 3–5 2/0 5/0 (4) 6–10 4/0 2/0 (5) >10 4/0 10/0 How many times has someone used a needle after you? 777/960 .009/.064 (0) Never 85/100 61/93 (1) Once 4/0 0/2 (2) Twice 0/0 7/0 (3) 3–5 times 0/0 7/2 (4) 6–10 times 2/0 9/0 (5) >10 times 8/0 16/2 How often have you cleaned needles before reusing them? 815/861 .025/.009 (0) Never reuse needles 83/98 63/81 (1) Every time 13/2 26/16 (2) Often 4/0 9/2 (3) Sometimes 0/0 0/0 (4) Rarely 0/0 2/0 (5) Never 0/0 0/0 How often have you used bleach to clean needles? 786/863 .072/.009 (0) Never reuse needles 85/98 61/81 (1) Every time 2/0 14/7 (2) Often 4/0 12/5 (3) Sometimes 6/2 2/2 (4) Rarely 0/0 9/2 (5) Never 2/0 2/2 Note: The numbers in parentheses to the left of the responses are the numbers used to derive composite scores. Responses, percentages, and statistical values for lifetime risk behavior (LT) are in regular font. Past-month risk behaviors (MO) are indicated with italics. ASP = antisocial personality disorder. Table options Substance abusers with ASP also differed significantly from substance abusers without ASP in terms of risky IVDU behaviors in the past 30 days. Again, the two groups differed in their frequency of IVDU over the past month, with 21% of subjects with ASP using drugs intravenously in the past 30 days versus 2% of subjects without ASP. The two groups also differed in the frequency of needle-cleaning and use of bleach over the past month. Table 3 shows responses on the sex risk behavior questions of the HRBS for the two groups of subjects. On individual items from which the overall lifetime sex risk score is derived, ASP subjects differed significantly from non-ASP subjects on two items: (1) the number of lifetime sex partners; and (2) the lifetime frequency of anal sex. Forty percent of ASP subjects reported more than 50 sexual partners in their lifetime, as compared with 15% of substance abusers without ASP. Additionally, although 97% of all subjects reported their sexual preference as heterosexual, 53% of ASP subjects engaged in anal sex during their lifetime, compared with only 35% of non-ASP subjects. Although not statistically significant, subjects with ASP also had a tendency toward less frequent condom use when exchanging sex for money or drugs. No differences were found between subjects with and without ASP in regard to frequency of condom use with either regular or casual sex partners. Table 3. Percentage of subjects reporting various sex risk behaviors during their lifetime (LT) and in the past month (MO) Non-ASP substance abusers (%) ASP substance abusers (%) Mann–Whitney U-test p Items and responses LT/MO LT/MO (LT) (LT) How many people have you had sex with? (n = 48) (n = 43) 728 .012 (0) None/None 0/40 0/51 (1) One/One 0/50 0/30 (2) 2–10 /Two 31/8 19/12 (3) 11–30/3–5 40/2 28/5 (4) 31–50/6–10 15/0 14/2 (5) >50/>10 15/0 40/0 How often have you used condoms when having sex with your regular partner(s)? 908 .305 (0) No regular partner or penetrative sex 2/40 2/56 (1) Every time 6/13 5/12 (2) Often 19/8 12/2 (3) Sometimes 17/2 19/2 (4) Rarely 23/2 19/0 (5) Never 33/35 44/28 How often have you used condoms when having sex with casual partners? 955 .531 (0) No casual partner or penetrative sex 2/85 2/77 (1) Every time 21/4 33/16 (2) Often 23/2 16/2 (3) Sometimes 21/6 21/0 (4) Rarely 17/2 5/0 (5) Never 17/0 23/5 How often have you used condoms when you have been paid for sex with money or drugs or when you have paid for sex with money or drugs? 834 .098 (0) No paid sex 52/92 30/84 (1) Every time 19/4 35/9 (2) Often 4/0 7/2 (3) Sometimes 8/2 7/0 (4) Rarely 8/2 5/0 (5) Never 8/0 16/5 How many times have you had anal sex? 806 .047 (0) No times 65/96 47/98 (1) One time 17/4 9/2 (2) Two times 4/0 5/0 (3) 3–5 times 2/0 23/0 (4) 6–10 times 4/0 7/0 (5) More than 10 times 8/0 9/0 Note: The numbers in parentheses to the left of the responses are the numbers used to derive composite scores. Responses, percentages, and statistical values for lifetime risk behavior are in regular font. Past-month risk behaviors are indicated with italics. Statistical analyses were not conducted on individual items of past-month sex risk behavior, see text. ASP = antisocial personality disorder. Table options Because no differences in past-month composite sex scores were noted between male substance abusers with ASP and without ASP, no statistical analyses were conducted on individual items. In general, however, about 50% of subjects in each group reported having sex in the past month. While many of those who reported sexual activity in the past month only had one partner, only about 12% of each group reported using condoms every time they had sex with regular partners. Finally, 12% of the sample reported exchanging sex for drugs or money in the past month, but only half of those who did so used a condom each time. Fig. 2 shows knowledge about HIV transmission and self-protective measures in ASP and non-ASP subjects. No differences were found between the two groups, t(89) = .20, p = .85. Mean percent correct on the HIV Knowledge Scale for subjects with and without ... Fig. 2. Mean percent correct on the HIV Knowledge Scale for subjects with and without antisocial personality disorder (ASP)