A Mixed-Methods Examination of The Relationship Between Alcohol Intoxication and Sexual Risk Behavior in Men Who Have Sex with Men

Abstract

HIV continues to be a serious public health concern among men who have sex with men (MSM). Experimental research suggests that alcohol has a causal role in increasing sexual risk behavior relevant to HIV and STI exposure among men who have sex with men (MSM). However, event-level research has provided mixed results, suggesting that alcohol does not affect sexual risk behavior for all individuals in all circumstances. Qualitative research has found that MSM generally perceive alcohol to increase engagement in sexual risk behavior but has provided limited insight into what factors moderate this effect. Guided by the Inhibition Conflict Model of Alcohol Myopia (ICM), and the Dual Control Model of Sexual Response (DCM), two studies explore the event-level effects of alcohol on sexual risk behavior in a cross-sectional sample of MSM (N=464). In study 1, a subsample of N=26 participants completed qualitative interviews on their perceptions of alcohol's effects on sexual risk behavior. Interview transcripts were coded using thematic analysis and themes were identified. Participants who perceived an effect of alcohol (N=11) identified many sexual risk behaviors that alcohol affected (i.e., condom use, communication with partners, partner selection, etc.) and perceived alcohol to diminish their inhibitions related to STIs. They also indicated that alcohol would be more likely to impact sexual risk decisions with new sexual partners because these partners are perceived as riskier. Participants who perceived no effects of alcohol (N=15) generally reported they used alcohol in moderate amounts or were unconcerned about STI risk and would therefore engage in the same sexual risk behavior whether they were drunk or sober. In study 2, event-level data from N=1049 sexual encounters were assessed using a series of generalized hierarchical linear regressions. Alcohol use showed inconsistent associations with sexual risk behaviors in the full sample but was consistently positively associated with sexual risk behavior for participants who did not use PrEP or were living with HIV and did not currently have an undetectable viral load. Further exploratory analyses indicated that for PrEP non-users, presence of inhibition conflict (i.e., simultaneously high sexual sensation seeking and concerns about HIV/STIs) moderated the relationship between alcohol use and sexual risk behaviors, with those indicating greater inhibition conflict showing stronger effects. Results of the two studies are discussed in the context of the limited research on the ICM and future directions for MSM-focused sexual health research integrating the ICM and DCM.