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Distilling risk: alcohol, unsafe sex and HIV transmission​

As a senior scientist at CAMH, Dr. Paul Shuper studies the links between alcohol and unsafe sex practices leading to HIV transmission.

It’s a unique subject area, one he fell into by chance. When Dr. Shuper stepped onto campus at Western University, intending to specialize in economics, he took a wide range of classes, including psychology. He expected to learn a lot; he didn’t expect to love it.

“Psychology was my favourite course, and I ended up majoring in it,” he says. “I really liked social psychology—aspects of behaviour and attitude change—specifically with respect to health practices.”

Dr. Paul Shuper with the mobile lab at World Pride in Toronto, June 27-29, 2014.

In graduate school, he began working with Dr. William Fisher, an expert in sexual and reproductive health behaviour and co-creater of the information-motivation-behavioural skills model, which is widely used in HIV prevention.

After completing his PhD at Western, Dr. Shuper worked with his mentor’s brother (and co-creator of the model), Dr. Jeffrey Fisher, during his post-doctoral fellowship at the University of Connecticut. There he had the opportunity became Co-Investigator on a five-year project in South Africa on HIV-prevention and intervention, funded by the U.S. National Institute of Mental Health.

“We worked with people who were living with HIV in South Africa, trying to help them overcome barriers to safer sex, with the ultimate goal of preventing new HIV infections. It was a randomized controlled trial that involved 16 clinics and 2,000 patients.”

It was a long but fruitful study: the intervention they developed worked. A paper on their findings is expected to be published later this year.

On alcohol, mental health, and HIV

When he began working at CAMH in 2007, Dr. Shuper conducted meta-analyses and systematic reviews of studies on alcohol use and unprotected sex; not surprisingly, the links between the two factors were confirmed. He and his team also found an association between alcohol use and unprotected sex among those who were HIV positive.

“The connection is quite significant,” he says. “We showed that not only are people who consume alcohol in general at increased risk of engaging in unprotected sex, but for those who use alcohol in sexual contexts - in other words, before or during sexual activity – the increased risk is almost twice as high.”

When looking at HIV transmission rates and alcohol use, Dr. Shuper is primarily looking at men who have sex with other men. It turns out that this group is disproportionately affected by HIV: an estimated 49 per cent of all new HIV infections and 55 per cent of current infections in Canada occur in this population. And in Ontario at least, sexual contact is the most common route of HIV exposure. Mitigating risky sexual behaviour, therefore, will go a long way toward reducing HIV infection in this population.

Recently, Dr. Shuper was involved in a meta-analysis of studies that determined alcohol use in populations at risk for HIV, and then tracked these populations over time to see who became infected with the virus. Although a clear link was established—drinkers were more likely to contract HIV—the study could not determine a cause-and-effect relationship, meaning that the alcohol consumption didn’t necessarily lead to HIV infection. As he points out, “Those predisposed to drinking alcohol might also be predisposed to having unsafe sex, perhaps due to an underlying risky personality trait.”  

Real-world application

The causal factor is something Dr. Shuper is currently trying to pin down in his current research at CAMH, which is funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the Canadian Institutes of Health Research (CIHR).

“I’m using CAMH’s unique barroom laboratory facility to identify alcohol’s causal role in unprotected sex through alcohol administration studies, which will be able to identify alcohol’s direct impact on risky situations.”

Most recently Dr. Shuper was at the World Pride street fair this June in Toronto, with the CAMH mobile lab, administering surveys and biological substance use screeners to Pride-goers to assess rates of substance use and risky sexual behaviours, as well as prevention strategies and safer sex practices.

The overall goal of his work is to identify barriers to safer sex in the real world, and to create and implement informed programs that the community and health providers can use to reduce HIV infection.

His work in South Africa still isn’t finished either. He’s a Co-Investigator on a new project looking to reduce alcohol use among HIV positive drinkers who are taking antiretroviral therapy. “We’re predicting that decreasing alcohol use among this group will lead to better medication adherence, and in turn, better viral suppression and improved health outcomes.”

Research aside, Dr. Shuper relishes opportunities such as World Pride to work in the community, alongside study participants, patients, and health care providers. “If I wasn’t doing research,” he says, “I’d be working in the community.”


Dr. Paul Shuper is an Independent Scientist in the Social, Prevention and Health Policy Research Department at CAMH.

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