Sexual Occasions Research Articles

Prevalence of Erectile Dysfunction among Type-2 Diabetes Mellitus & Availability of Treatment Options in Pakistan

Introduction Erectile dysfunction has been defined as failure to obtain and maintain an erection sufficient for sexual intercourse or decreased erectile turgidity on 75% of sexual occasions, lasting for at least six months. Estimates of the prevalence of erectile dysfunction (ED) in men with diabetes range from 20% to 85% [1]. Type 2 Diabetes patients have a high risk of sexual dysfunction in men; three times increased risk of ED was seen in diabetic compared with nondiabetic men. There are multiple risk factors which include, obesity, age-related hormonal changes metabolic syndrome in young patients, it is associated with a greater increase in the risk of future cardiac events as compared to its first detection in older males. Aim The aim of the study is to determine the relative prevalence of Erectile Dysfunction in the Pakistani population attending diabetes with help of the SHIMS score/IELTS. To establish further management of this commonly under-recognized, under-discussed, and commonly untreated complication of diabetes. But it is also one of the most treatable diabetic complications. It is a “couple’s disorder,” affecting both the patient and his partner. In Pakistan, there is not much evidence & options for treatment are not ideally available inclusive of the availability of PD5 drugs. Methodology Male patients with diabetes mellitus having poor glycemic control, hypertension, and hyperlipidemia with or without active complaint of Erectile Dysfunction attending The Diabetes Centre (TDC) during the study period were enrolled in the study. 319 males with diabetes were examined by the Diabetologist, endocrinologist, and clinical psychologist. Patients were surveyed using the five items version of the International Index of Erectile Dysfunction questionnaire, also known as the Sexual Health Inventory of Men (SHIM) to determine the presence and severity of ED and the efficacy of ED treatment conditions. Discussion and Results In the study, a total of 319 diabetic patients were enrolled and assessed/examined. Those with severe ED were found to have poor glycemic control, abnormal lipid profile, with BMI. 19%, 15%, and 31% of patients scored as severe, moderate, and mild to moderate ED respectively; 65% were scored as suffering in ED, whereas 20% of diabetic male patients have a higher proclivity of developing server ED. Male patients with poor glycemic control & hyperlipidemia were suffering from severe erectile dysfunction. Conclusion The accumulated percentage of diabetic male patients who have signs of ED is higher therefore the prevalence of ED is too high in diabetic male patients. In addition, there are no appropriate management options like the availability of safe drugs and treatment in Pakistan.

Sexual and reproductive health in Britain during the first year of the COVID-19 pandemic: cross-sectional population survey (Natsal-COVID-Wave 2) and national surveillance data

ObjectivesTo assess sexual behaviour, and sexual and reproductive health (SRH) outcomes, after 1 year of the COVID-19 pandemic in Britain.Methods6658 participants aged 18–59 and resident in Britain completed a cross-sectional...

Erectile Dysfunction in a Male Patient With Limited Cutaneous Systemic Sclerosis

A 24-year-old male with a 3-year history of limited cutaneous systemic sclerosis (LcSS) was referred to the urology clinic by his rheumatologist because of erectile dysfunction (ED). He complained of his worsening ED over the past two years. His international index of erectile function (IIEF) score was 5, indicating severe ED. He reported no morning erection and experienced some degree of turgidity without rigidity in sexual occasions. Digital ulcers and gastroesophageal reflux were his only presentations other than ED. His history was negative for pulmonary hypertension and renal crisis.

Trends in testing of sexually transmissible infections (STIs), sexual health knowledge and behaviours, and pornography use in cross-sectional samples of young people in Victoria, Australia, 2015-21.

Sexually transmissible infections (STI) are prevalent and increasing among young Australians. This study examined trends in STI testing, sexual health knowledge/behaviours, and pornography use in young people aged 15- 29years in Victoria, Australia between 2015 and 2021. Seven online cross-sectional surveys were conducted in a convenience sample of young people, recruiting a total of 7014 participants (67% female). Logistic regression analyses determined trends over time in binary outcomes. There was a decrease in reports of lifetime vaginal sex over time, while lifetime anal sex remained stable. Among those who had ever had vaginal sex, results showed an increase in the use of long-acting reversible contraceptives on the last occasion of vaginal sex. There was no change in STI testing or condom use with all partner types. Knowledge of STIs and sexual health changed over time: the proportion knowing that chlamydia can make women infertile decreased over time, while knowledge that taking the pill does not reduce fertility increased. There was no change in pornography use after adjusting for demographic variables. Although uptake of long-acting contraceptives increased, STI knowledge and testing, as well as consistent condom use, remained low. Public health interventions should continue to address these critical components of STI prevention.

A randomized clinical trial evaluating the impact of counselor training and patient feedback on substance use disorder patients' sexual risk behavior

IntroductionHigh risk sex—such as sex with multiple partners, condomless sex, or transactional or commercial sex—is a risk factor in individuals with substance use disorders (SUDs). SUD treatment can reduce sexual risk behavior, but interventions to reduce such behavior in this context have not been consistently effective. This study sought to determine if the impact of treatment on sexual risk behavior can be increased. MethodsIn a nested 2 × 2 factorial repeated measures design, we examined outcomes of two interventions: training for counselors in talking to patients about sexual risk; and availability to both counselors and patients of a personalized feedback report based on patient self-report of sexual behavior. Counselors received either a brief, information-based, Basic Training, or a multi-session, skills-based Enhanced Training. Their patients completed an audio-assisted computerized assessment of sexual behavior and received either No Feedback or a Personalized Feedback Report (PFR). Four hundred seventy six patients participated. Patient follow-up occurred 3- and 6-months postbaseline. Primary patient outcome measures were Number of Unsafe Sex Occasions (USO) and whether patients reported talking about sex in counseling sessions (Discussed Sex), both in the past 90 days. Secondary outcomes included Number of Sexual Partners, Sex Under the Influence of Substances, and Perceived Condom Barriers. ResultsPatients of Enhanced-condition counselors compared to those of Basic-condition counselors were more likely to report talking about sex with their counselor at 6-month follow-up. Personalized feedback also increased the likelihood of reporting counselor discussions at 6-month follow-up. Neither the training nor the feedback condition affected USO, Number of Partners, or Sex Under the Influence. DiscussionWe discuss why these two interventions apparently altered counselor-patient communication about sexual risk behavior without affecting the behavior itself.

Randomized controlled trial of twelve-step volunteer linkage for women with alcohol use disorder leaving jail

BackgroundAlcohol use disorder predicts poor health outcomes among women returning to the community from jail. Twelve-step self-help groups are free and accessible to women leaving jail, but reaching out to strangers can pose a barrier. Pilot work suggested that a volunteer-led “warm handoff” may increase post-release twelve-step self-help group attendance. MethodsThis randomized trial evaluated the effectiveness of a warm handoff intervention on post-release twelve-step attendance and alcohol use. Participants (189 women with alcohol use disorder) were recruited in jail and followed for 6 months after release. Participants were randomized to: (1) a warm handoff, in which a female twelve-step volunteer met with each woman individually in jail and the same volunteer attended the woman’s first twelve-step meeting with her after release; or (2) enhanced standard care (a list of meetings and community resources). Outcomes included days abstinent from alcohol, drinks per drinking day, alcohol-related problems, twelve-step attendance, twelve-step affiliation, network support for abstinence, number of unprotected sexual occasions, and drug using days. ResultsAmong intervention participants, only 66 % were aware that the volunteer tried to contact them after jail, only 38 % reported post-jail contact with their volunteers (typically phone), and only four went to meetings with their volunteers post-release. Of 8 post-release outcomes, intervention effects differed on only one (alcohol-related problems). ConclusionAlthough twelve-step self-help group attendance predicted alcohol abstinence, the volunteer-led warm handoff intervention did not increase twelve-step attendance. The twelve-step tradition of Attraction may inhibit the active outreach required to connect women to services after jail release.

Assessment of meat demand: A case study in the University of Ibadan for beef enterprise

Poor adherence to food safety and wholesome practices in meat processing and handling is a common phenomenon in some public abattoirs in Nigeria. The quality of beef consumed by the University community is an issue of concern. Information on the extent of beef patronage has not been documented. Thus, beef demand at the University of Ibadan abattoir was assessed. Ante-mortem and post-mortem inspections by the University Veterinarian were performed on slaughter days from January 2013 to April 2015. The data collected were customer: day of purchase, Department/Unit, sex and rank. The quantity demanded and the parts requested were also noted. Data were analyzed using descriptive statistics. The results showed that a total of 22,884 contacts were recorded. An increase in patronage from 42.24% in 2013 to 57.76% in 2014 was evident. Women (53.60%) requested for meat than male counterpart. The requests for 1-2kg, 2-4kg and above 4kg at a time were 58.9%, 19.1% and 10.0% respectively. For the day of purchase, the patronage was higher on Fridays (59.20%) as compared to Wednesdays. The last week of the month attracted higher demand (36.20%) than weeks 1 (21.0%), 2 (22.3%) and 3 (20.5%). A noticeable increase in demand was during festive periods. A high percentage occurred in the number of customers that specified the actual parts (63.5%) of the meat requested and those that did not while females specified more (57.82%) than males. Highest preference for special parts was observed among the Professors (45%). More patronage was observed for people at closer Departments/Unit to the abattoir. It may be concluded that day of slaughter, proximity to slaughter house, sex, status and special occasions are vital factors that affect beef demand enterprise in the University of Ibadan.

Challenges and opportunities in the science of research to practice: lessons learned from a randomized controlled trial of a sexual risk-reduction intervention for psychiatric patients in a public mental health system

Objective:Human immunodeficiency virus (HIV) prevention efficacy trials with psychiatric patients have been conducted in research settings in high-resourced countries, establishing short-term efficacy for reducing sexual risk behavior. None has been implemented within systems of care. In the last decade, overcoming this research-to-practice gap has become a focus of implementation science. This paper describes the first and only HIV Prevention intervention trial for psychiatric patients conducted in real-world outpatient psychiatric settings facilitated by trained clinic-based providers.Methods:The HIV Prevention intervention, which uses the Information-Motivation-Behavioral Skills model to achieve sexual risk-reduction, was rigorously adapted to the local context and clinic services’ needs. Participants from eight clinics were randomized to HIV Prevention or Health Promotion conditions.Results:HIV Prevention participants showed significant improvement in Information-Motivation-Behavioral domains; in this group, behavioral intentions were associated with significantly fewer unprotected sex occasions, but reduction of unprotected sex occasions was similar in both conditions.Conclusion:Our trial was conducted before implementation studies became widely funded. Transporting an intervention to a new culture or into real-world practice settings may require adaptations. Our results demonstrate that clear guidelines are needed regarding whether to conduct efficacy, effectiveness, and/or implementation research as the most appropriate next step.Clinical trial registration:NCT00881699

Testing the Synergistic Effects of Depression, Anxiety, and Substance Use in Unsafe Sex: a Cross-sectional Study

Condom use is the most affordable method to prevent sexually transmitted infections (STIs). Anxiety, depression, and substance use have been used as covariates of condom use, but little is known about the possibility of synergistic effects. The objective of this study was to determine the synergist effect of depression, anxiety, and substance use in unsafe sex. Individuals receiving residential treatment for substance use were recruited in 21 centers in Mexico City. Data on substance use, depression (PHQ-9), anxiety (GAD-7), and condom use (number of unsafe sex occasions) was collected. Four Poisson regression models were adjusted to compare the additive or interactive effect of these variables. We found that model 2 (anxiety and depression interactive model) showed a better fit when compared with its additive-only counterpart (model 1), χ2[1] = 29.538, p < .001; model 4 (anxiety, depression, and substance use interactive model) had a better fit that model 3 (anxiety, depression, and substance use additive model), χ2[1] = 23.479, p < .001. Models with interactive terms produced better predictions of condom use. Only depression symptoms displayed a synergistic effect with substance use. These findings may be the result of unique components of the symptoms, and they stress the importance of including interactive terms when testing the associations or the effects of mental health variables in health outcomes, particularly in condom use.

A Brief Clinic-Based Intervention to Reduce Alcohol Misuse and Sexual Risk Behavior in Young Women: Results from an Exploratory Clinical Trial.

This exploratory trial determined the feasibility, acceptability, and preliminary efficacy of a brief intervention (BI), supplemented with text messaging and a curated Web site, on alcohol use and sexual risk behavior among young women. Young women seeking care at a reproductive health clinic were screened for alcohol misuse and sexual risk behavior. Those who screened positive and who agreed to participate (N = 48; M = 22.67years) were randomized to either (a) a brief in-person session during which personalized feedback regarding alcohol use and sexual risk taking was provided and discussed, or (b) a control condition. Feasibility was assessed by recruitment and retention rates. Acceptability was assessed with participant ratings of their intervention. Efficacy was measured using self-reported alcohol use and sexual behavior at baseline and during a 3-month follow-up. We supplemented the quantitative data with qualitative data from semi-structured interviews. Feasibility data indicated that 64% of eligible women agreed to participate, 74% of eligible women were enrolled, and 86% of enrolled women were retained through follow-up. Acceptability data showed that women who received the BI reported strong satisfaction with their intervention (M = 4.65 vs. 3.98 on a five-point scale) and also reported that text messaging was helpful (M = 4.73 on a seven-point scale) and acceptable (M = 5.27 on a seven-point scale). Qualitative data provided additional support for BI feasibility and acceptability. Efficacy data showed that women in both conditions reduced alcohol use and sexual risk behavior over time; women who received the BI reduced their maximum daily alcohol intake more than controls (BI from 7.68 to 4.82 standard drinks vs. control from 6.48 to 5.65; Wald χ2 = 4.93, p < .05). Women in the BI reported fewer occasions of condomless sex (median = 2.50) than controls (median = 5.00) at the follow-up, but this difference was not statistically significant (OR = 0.61, 95% CI [0.32, 1.15]). A brief intervention, supplemented with text messaging and a Web site, that targeted alcohol use and sexual behavior was feasible and acceptable to young women and led to lower levels of alcohol misuse and sexual risk behavior.

Depressive symptoms as a longitudinal predictor of sexual risk behaviors among African-American adolescents.

Understanding individual level factors associated with sexual risk behaviors among African-American adolescents remains an important public health priority. The current secondary data analysis examined the longitudinal association between a baseline assessment of depressive symptoms and sexual risk behaviors reported 6 months later; the purpose was to determine whether the association of depressive symptoms to risky sex varies as a function of gender. A secondary aim was to examine self-efficacy for sex refusal and condom use assessed at a 3-month follow-up as mediators of the depressive symptoms-sexual risk relationship. The sample consisted of 782 sexually active African-American adolescents (Mage = 15.3 years, SD = 1.08; 54% female) recruited to participate in a sexual health intervention trial. Data analyses focused on vaginal sex, and outcomes included: (a) sexual activity with 2 or more partners in the previous 3 months; (b) the relative frequency of condom use in the previous 3 months; (c) noncondom use at last occasion of sex; and (d) positive sexually transmitted infection (STI) screening. Depressive symptoms predicted sex with 2 more partners for female participants, but no other risk markers for the sample as a whole. However, there was a significant indirect effect of depressive symptoms on condomless sex via decreased condom use self-efficacy for both male and female adolescents. These findings have important implications for HIV/STI prevention, in which behavioral interventions may benefit from modules that include a focus on the influence of mood on self-efficacy for safer sex practices. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Changes in, and factors associated with, frequency of sex in Britain: evidence from three National Surveys of Sexual Attitudes and Lifestyles (Natsal)

ObjectivesTo examine changes over time in the reported frequency of occurrence of sex and associations between sexual frequency and selected variables.DesignRepeat, cross sectional, population based National Surveys of Sexual Attitudes...

The Association Between African American Parent-Child Sex Communication and Adolescent Condomless Sex.

African American adolescents are at elevated risk for HIV and sexually transmitted infections. Risk reduction efforts have focused on parent-child communications, despite inconsistent findings regarding their association with adolescent sexual risk behaviors. The present study included sexually active African American adolescents and their parents/guardians (N = 125 dyads). All participants reported on frequency of sexual health conversations and adolescents reported recent occasions of protected and condomless sex. Analyses examined the congruence between parent-child communication reports and the association between this congruence and adolescent condomless sex. Parents and adolescents disagreed on the frequency of sexual health communication: 30% of parents reported such conversations as frequent, whereas only 2% of adolescents did. Parent-reported sex communication was negatively associated with adolescent condomless sex, while adolescent-reported communication was not. The moderation hypothesis was supported in that adolescent-reported sex communication was negatively associated with adolescent condomless sex only among parent-child dyads high in agreement on sexual health communication. Promoting parent-child conversations regarding sexual health, with attention to relational characteristics of the conversations, offers a promising approach to sexual health promotion and disease prevention for African American youth.

“Are men sexually harassed?”

AbstractSinceMacKinnon’s (1979)ground-breaking work in which she coined the term sexual harassment, there has been very little consensus as to what it actually is. Using callers’ stories of male sexual harassment taken from Kenyan talk radio, the purpose of this paper is to analyse the in situ production of an emic definition of (male) sexual harassment. Further, using positioning theory as a methodology, this paper aims (1) to make visible the gendered identity work that defining, or not defining, an event as male sexual harassment occasions and (2) to show how hegemonic masculinity is achieved through stories and their evaluation by the radio host and other callers who talk certain masculinities into being as normative and others as deviant.

Sociodemographic and Substance Use Disorder Determinants of HIV Sexual Risk Behavior in Men and Women in Outpatient Drug Treatment in the NIDA National Drug Abuse Treatment Clinical Trials Network

ABSTRACTBackground: Sexual risk behavior is now the primary vector of HIV transmission among substance users in the United States with gender as a crucial moderator of risk behavior. Objectives: The purpose of this study was to examine gender differences in factors (age, race/ethnicity, education) that predict main-partner unprotected sexual occasions (USO) using the unique platform of two parallel NIDA National Drug Abuse Treatment Clinical Trials Network gender-specific safer sex intervention trials. Methods: Baseline assessments of male (N = 430) and female (N = 377) participants included demographic characteristics; past 3-month sexual activity; and a diagnostic assessment for alcohol, cocaine/stimulant, and opioid use disorders. Using mixed effects generalized linear modeling of the main outcome USO, two-way interactions of gender with age, race/ethnicity, and education were evaluated and adjusted by alcohol, cocaine/stimulant, or opioid use disorder. Results: When adjusted for alcohol use disorder, the interaction of education and gender was significant. For men, a high school or greater education was significantly associated with more USO compared to men with less than high school. For women, greater than high school education was significantly associated with less USO compared to women with a high school education. None of the other interactions were significant when adjusted for cocaine/stimulant or opioid use disorder. Conclusions/Importance: This study demonstrates gender differences in the relationship of education, alcohol use disorder, and main-partner USO in individuals in substance abuse treatment. This underscores the importance of considering demographic and substance use factors in HIV sexual risk behavior and in crafting prevention messages for this population.

Study protocol: Community Links to Establish Alcohol Recovery (CLEAR) for women leaving jail

PurposeThis article describes the protocol for a randomized effectiveness trial of a method to link alcohol use disordered women who are in pretrial jail detention with post-release 12-step mutual help groups. BackgroundJails serve 15 times more people per year than do prisons and have very short stays, posing few opportunities for treatment or treatment planning. Alcohol use is associated with poor post-jail psychosocial and health outcomes including sexually transmitted diseases and HIV, especially for women. At least weekly 12-step self-help group attendance in the months after release from jail has been associated with improvements in alcohol use and alcohol-related consequences. Linkage strategies improve 12-step attendance and alcohol outcomes among outpatients, but have not previously been tested in criminal justice populations. DesignIn the intervention condition, a 12-step volunteer meets once individually with an incarcerated woman while she is in jail and arranges to be in contact after release to accompany her to 12-step meetings. The control condition provides schedules for local 12-step meetings. Outcomes include percent days abstinent from alcohol (primary), 12-step meeting involvement, and fewer unprotected sexual occasions (secondary) after release from jail. We hypothesize that (Minton, 2015) 12-step involvement will mediate the intervention's effect on alcohol use, and (O'Brien, 2001) percent days abstinent will mediate the intervention's effect on STI/HIV risk-taking outcomes. Research methods accommodate logistical and philosophical hurdles including rapid turnover of commitments and unpredictable release times at the jail, possible post-randomization ineligibility due to sentencing, 12-step principles such as Nonaffiliation, and use of volunteers as interventionists.

Safetxt: a pilot randomised controlled trial of an intervention delivered by mobile phone to increase safer sex behaviours in young people

ObjectiveTo test the procedures proposed for a main trial of a safer sex intervention for young people delivered by mobile phone text message (‘safetxt’).Design and settingPilot randomised controlled trial. Participants...

Rapid Human Immunodeficiency Virus Testing and Risk Prevention in Residents of Battered Women's Shelters

BackgroundHuman immunodeficiency virus (HIV) infection and intimate partner violence (IPV) are interconnected public health problems. However, few HIV prevention interventions address the unique needs of IPV survivors in shelter and none of the Centers for Disease Control and Prevention’s best-evidence risk reduction interventions adequately explore the complex relationship between IPV and HIV risk. Although battered women's shelters provide a safe and supportive environment for women in crisis, most do not offer HIV risk reduction services or sexual safety planning. MethodsThis study evaluated the feasibility, acceptability, and initial efficacy of rapid HIV testing and brief risk prevention intervention developed for residents of battered women's shelters. The Safe Alternatives For Empowered sex for intimate partner violence intervention (SAFE-IPV) was evaluated in an open trial (N = 98). Participants were assessed with a series of standardized interviews and self-reports at screening and 3 months after leaving the shelter. ResultsFew eligible participants declined SAFE-IPV and participants who received SAFE-IPV reported high levels of satisfaction. No participants in the open trial tested positive for HIV. However, participants reported significantly fewer unprotected vaginal and anal sexual occasions and increased intentions to engage in risk preventative behaviors 3 months after leaving shelter compared with the 3 months before shelter. Additionally, participants reported significant improvements on HIV risk factors addressed in SAFE-IPV at the 3-month follow-up (i.e., reduced emotional, physical, and sexual harm by abuser, posttraumatic stress symptoms, hazardous alcohol use, and drug use). DiscussionThese results extend prior research on HIV prevention with women with IPV, demonstrating the acceptability, feasibility, and initial efficacy of SAFE-IPV within battered women's shelter settings.

Nepalese Trekking Guides: A Quantitative Study of Sexual Health Knowledge &amp; Sexual Behaviour

Background: Tourism, a global industry, brings with it a number of public health problems, one of which is the spread of sexually transmitted infections transmitted between travellers and hosts. Previous studies have largely focused on sex workers and sex tourists.Objective: To assesses sexual behaviour, knowledge and condom use among male trekking guides in Nepal.Methods: A self-administered questionnaire survey (n=324) was conducted using snowball sampling amongst men working as mountain trekking guides in Nepal. Results: Most respondents (59%) had initiated sex before the age of 18. Most (84 %) reported sexual relations with a woman other than their partner, 46% reported foreign partners, 43% had Nepalese partners, and 28% had concurrent foreign and Nepalese partners. Most (70 %) reported ever having sex with a foreign woman and two-thirds had had sexual intercourse with foreign women in the previous 12 months. Participants’ age, education status, age of first sex, smoking and drinking habits and English proficiency were significant predictors of having sex with foreign women. About 60% reported condom use during their most recent occasion of extra-martial sex. A similar proportion had used a condom during last sexual intercourse with a foreign woman. The likelihood of condom use was associated with a guide’s age, educational level, ethnicity, age of first sex and work experience.Conclusions: Most trekking guides reported sexual relations with foreign women as well as irregular use of condoms. Although sexual health knowledge about among trekking guides is high, some misconceptions still result in unsafe sex. Hence there is an urgent need to revise the existing training for trekking guides and implement appropriate health promotion programmes.Health Renaissance 2014;12(3): 180-189

The Information\u2013Motivation\u2013Behavioral Skills Model Revisited: A Network-Perspective Structural Equation Model Within a Public Sexually Transmitted Infection Clinic Sample of Hazardous Alcohol Users

The information–motivation–behavioral skills (IMB) model is useful for understanding sexual risk behavior, but has not been tested with hazardously-drinking sexually transmitted infection (STI) clinic patients, a subpopulation at greater HIV risk, or with a network-perspective sexual risk behavior outcome. Participants (N = 569) were STI clinic patients who screened positive for hazardous drinking and risky sexual behavior. Sexual risk behavior (SRB) was operationalized as a latent variable with three indicators: (1) number of sexual partners, (2) number of unprotected sex occasions with primary partner, and (3) number of unprotected sex occasions with non-primary partner(s). Preliminary analyses suggested SRB was best operationalized as a latent variable with two indicators, while unprotected sex with primary partners should be considered separately. In structural models with good fit, the IMB model was generally supported. The IMB model functioned differently for non-primary and multiple partners compared to primary partners in STI clinic patients with hazardous alcohol use.