Addressing Psychosocial Cofactors

As discussed in the Psychosocial Issues module, when addressing sexual risk behaviors and decision-making, it is important to consider 3 potential cofactors associated with increased sexual risk behavior among people with HIV: substance abuse, mental illness, and a history of childhood sexual abuse.30

Substance Use

People with HIV have considerably higher rates of substance use compared with the general population.31 In many cases, youth who have been exposed to trauma, racism, discrimination, poverty, and other social problems are at higher risk of engaging in the use of substances as a means of self-medicating. From the perspective of HIV transmission, alcohol and drug use are very significant risk factors that can bring about sexual risk taking as well as the unsafe sharing of needles among injection drug users (IDUs).

The chances of transmitting disease by means of shared syringes are very high. IDUs are at risk of contracting not only HIV but also bloodborne pathogens such as hepatitis B and C, which are far more virulent than HIV and thus easier to transmit. Another concern is the possibility of coinfection with HIV and viral hepatitis. The best way for an IDU to avoid contracting HIV is to stop injecting drugs. Referrals to drug treatment programs can be helpful for users who are ready to quit. However, if recreational drugs, hormones, or steroids are used, sterile needles substantially reduce the risk of HIV infection. If new needles are unavailable, IDUs are advised to avoid sharing needles or other injection drug equipment. In the event that sharing cannot be avoided, needles should be cleaned thoroughly with bleach and water. Providers can help by telling patients how to obtain sterile syringes through exchange programs and pharmacies.

For many HIV-infected youth, sex and drug use are linked activities. Studies have found that young people using substances tend to initiate sex earlier and that sexually experienced teens are more likely to initiate substance use.32 About 9 in 10 young people say their peers use alcohol or drugs before having sex at least some of the time.1 Large numbers of young people report they have engaged in risky sexual behavior while under the influence of drugs and alcohol, including having intercourse without a condom, "going further" sexually than they had planned, and having sex with more partners. Using drugs that cause euphoria (eg, ecstasy, amphetamines) presents an especially high risk of engaging in unsafe sexual activity.

Substances also increase the likelihood of negative sexual experiences and compromise the ability to give sexual consent. Alcohol and drugs also increase the risk of sexual violence, with alcohol implicated in two thirds of date rape incidents.33

It is theorized that some drugs increase HIV transmission rates by means other than lowering judgment and inhibition. Drugs that delay ejaculation (such as amphetamines, nitrates, and crack cocaine) lead to prolonged and more vigorous sexual activity, increasing the risk of trauma to the genitals associated with higher HIV transmission rates.2

Teens are often unaware of the negative effects of substance use on healthy sexual function. Alcohol and narcotics decrease libido, arousal, and orgasm. Although amphetamines initially increase sexual desire, they can cause impotence and long-term sexual dysfunction, which is why patients using amphetamines often seek erectile dysfunction medications such as Viagra, Cialis, and Levitra.

Because of the effects of drug use on judgment and other factors that increase risk-taking behaviors, providers should encourage patients to receive treatment for their substance use issues as part of risk-reduction efforts. See the Psychosocial Issues module for strategies that can help providers address substance use among HIV-infected adolescent populations.


  1. Kalichman SC, Gore-Felton C. Trauma symptoms, sexual behaviors, and substance abuse: correlates of childhood sexual abuse and HIV risks among men who have sex with men. J Child Sex Abus. 2004;13(1):1-15.
  2. Kalichman SC, Simbayi LC. Sexual assault history and risks for sexually transmitted infections among women in an African township in Cape Town, South Africa. AIDS Care. 2004 Aug;16(6):681-9.
  3. What Are Substance Abusers' HIV Prevention Needs? Center for AIDS Prevention Studies at the University of California San Francisco. 1996.
  4. Substance Abuse and HIV/AIDS in the United States. U.S. Department of Health and Human Services - Health Resources and Services Administration - HIV/AIDS Bureau. June 2006.
  5. Santelli JS, Robin L, Brener ND, et al. Timing of Alcohol and Other Drug Use and Sexual Risk Behaviors Among Unmarried Adolescents and Young Adults. Family Planning Perspectives. Volume 33(5). September/October 2001.
  6. Youth and Alcohol: Dangerous and Deadly Consequences, Office of the Inspector General, U.S. Department of Health and Human Services, 1992.