1. Association of PTSD, Alcohol, and Sex Risk: Support for Integrated Treatment
Nadine R. Mastroleo, PhD
Assistant Professor (Research)
Center for Alcohol and Addiction Studies
Department of Behavioral and Social Sciences
School of Public Health
Support: P01 AA019072; R01 AA A1;
Center for AIDS Research (CFAR) Developmental Award; U24AA022003

2. PTSD Childhood/Adult Sexual Abuse Alcohol Use H I V RK
Alcohol Use
Interpersonal Violence
PTSD
Drug Use Re
Victim-ization
Substance Abuse
Risky Sex
General Trauma
Military
Other factors

3. PTSD, Alcohol & Sex Risk
Between 35-50% of individuals in addiction treatment programs have a diagnosis of PTSD in their lifetime and 25-42% have a current PTSD diagnosis.
Alcohol use has been associated with multiple forms of sex-risk behavior (unprotected sex, multiple sex partners, sex outside of marriage, sex in exchange for money or other goods).
Relationship between PTSD and HIV risk may be bidirectional (e.g., forced unprotected sex associated with risk for HIV and PTSD)
Increased risk of excessive alcohol use among victims of childhood abuse or neglect is consistent and stable into middle adulthood (e.g., age 40; Widom et al., 2007).
Alcohol-dependent patients with a history of sexual abuse are more likely than nonabused patients to relapse to alcohol use (87 vs. 63%) and to relapse more quickly (median time to first drink = 60 vs. 115 days) in the first year following inpatient treatment for alcohol dependence (Greenfield et al. 2002).
(Back et al., 2000; Brady et al., 2004; Brown et al., 1995; Cacciola et al., 2001; Dansky et al., 1996; Jacobsen et al., 2001; Mills et al., 2005; Ouimette et al. 1997).

4. PTSD & HIV Risk
Several studies have shown that PTSD is associated with sexual HIV risk behaviors and HIV seropositive status (Stiffman et al., 1992; Wyatt et al., 1998; Wyatt et al., 2002).
Those who experienced childhood sexual abuse are at increased risk of developing PTSD, engaging in subsequent HIV risk behaviors, and HIV transmission.
PTSD and HIV risk vary according to presence of different PTSD symptoms (e.g., avoidance, hyperarousal, re-experiencing trauma).
Re-experiencing symptoms
Flashbacks—reliving the trauma over and over, including physical symptoms like a racing heart or sweating
Bad dreams
Frightening thoughts.
Avoidance symptoms
Staying away from places, events, or objects that are reminders of the experience
Feeling emotionally numb
Feeling strong guilt, depression, or worry
Losing interest in activities that were enjoyable in the past
Having trouble remembering the dangerous event.
Hyperarousal symptoms
Being easily startled
Feeling tense or “on edge”
Having difficulty sleeping, and/or having angry outbursts.

5. PTSD and Symptom Clusters
PTSD Symptom Clusters
Moderate to severe re-experiencing associated with multiple sex partners and unprotected sex
Avoidant = less likely to engage in unprotected sex
Hyperarousal may trigger individuals to seek sexual stimulation , engage in risker sex, and difficulty in negotiating safe sex
Specific symptoms of PTSD may uniquely impair communication and are often associated with alcohol use (e.g., emotional numbing).
In women, the link between PTSD and risk behaviors may be due to a woman’s inability to verbally negotiate with partners due to impaired communication with intimate partners (McFarlane & Bookless, 2001).
For women previously victimized by men, an inability to discuss healthier behavior may be due to a fear of revictimization (Hobfoll, 2003; Ickovics & Rodin, 1992; Jemmott, 1995).
High rates of PTSD have been found among HIV+ women, many of whom have experienced repeated traumas associated with PTSD, such as childhood sexual abuse and intimate partner violence (Kalichman et al., 2002; Simoni & Ng, 2000; Wyatt et al., 2002)
PTSD and Symptom Clusters
El-Bassel et al., 2011

6. Summary
Taken together, in samples of individuals with a history of sexual violence and PTSD, alcohol and drug use and risky sexual behaviors are common.
Both men and women are impacted by the intersection of alcohol use, PTSD, and sexual risk.

7. Sex-Risk and Alcohol Feedback in the Emergency Room
PI: Monti; Co-Investigators: Barnett, Colby, Kahler, Mastroleo, & Operario

8. Brief Motivational Intervention (BMI)
Research Design
ER patient screening
Brief Advice (BA)
Brief Motivational Intervention (BMI)
Ineligible
Brief Advice- typically about 5 minutes in which the Tx provider tells the patient they are drinking above the NIAAA recommended levels for safe drinking and are engaging in risky sex which puts them in danger of contracting HIV or a STD. We then offer them resources (also a handout on safe drinking and safe sex) and the option of getting HIV testing at the hospital
Screening and Eligibility
Alcohol
Alcohol use past month
AUDIT: Men = 8 or higher, Women = 6 or higher
Past 3 month Binge positive if AUDIT negative
Sex Risk (past 3 months)
Multiple sex partners
Condom use (Never, Sometimes, Usually)
Unsure of partners monogamy (i.e., HIV risk status)
Sex under influence of alcohol and/or drugs
MI is between minutes (on average)

9. PTSD and Alcohol Use
Of the larger sample, 60% (n = 220; 57.3% female) were positive for past 30 day PTSD symptoms on the Post-Traumatic Stress Disorder Check List-Civilian.
Patients reported an average of 8.3 drinks (SD=7.4) per drinking day and 7.0 (SD=7.8) heavy drinking days over the past 3 months
Patients positive for PTSD reported significantly more drinking days, number of heavy drinking days, and average number of drinks per drinking day (all ps < .001).
N = 372, 53.7% female
Age Mean 30.0 (SD = 9.5); Range 18-58
15.0% Hispanic or Latino
76.8% White
40.1 % GED or less

10. PTSD and Sex Risk
Patients with PTSD symptoms reported an average of 13.9 (SD=28.7) sex events with a non-steady partner without a condom.
Patients reported 7.9 (SD=20.3) sex events without a condom with a non-steady partner under the influence of alcohol during the past 3 months.
N/S differences between PTSD +/- patients.

11. Number of Drinking Days/Month
*p = .002
Number of Drinking Days per month

12. Number of Heavy Drinking Days
*p = .017
Number of Heavy Drinking Days per month

13. % Unprotected Sex Days with Non-Steady Partner
*p = n/s

14. % Unprotected Sex Days with Non-Steady Partner + Alcohol

15. Conclusions
Continued support for the association between PTSD, Alcohol Use, and Sex Risk Behaviors.
Consistent with alcohol treatment research, individuals with PTSD symptoms remain a challenging population to treat.
Equally (or more) challenging are efforts to reduce HIV risk behaviors with this population.
When designing HIV prevention interventions essential to take PTSD into account and develop integrated treatment approaches.

16. Thank You!
Questions???