Most of the men in this cohort displayed a pattern of abstaining or infrequent use over time whereas approximately 10 % who used daily or near daily at their index visit continued this pattern of use over their follow-up visits. Overall, our analysis suggested that these patterns of marijuana use over time were similar for both HIV+ and HIV− participants. In the analysis among all men, HIV+ status was associated with membership across all three trajectory groups reporting any marijuana use. Among HIV+ participants, having a detectable HIV RNA over time was associated with increasing marijuana use only among the men who increased their marijuana use during the follow-up period. Self-reported ART use over time in HIV+ men was associated with reducing marijuana use in the abstainer/ infrequent and increaser groups. Overall, alcohol consumption, cigarette, stimulant/ recreational drug use and IDU over time were associated with increasing marijuana use in nearly all trajectory groups. To the best of our knowledge, we are not aware of any previous study that has examined trajectories of marijuana use among HIV+ and HIV− MSM over a long period of follow-up. Prior studies that have assessed trajectories of marijuana use have focused on adolescents transitioning into young adulthood or racial/ethnic minorities, with a few studies reporting trajectories of use covering adulthood. Direct comparisons of the results from our study with prior research may not be straightforward due to the different populations studied and age periods covered.
However, nearly all studies on trajectories of marijuana use have identified a group that abstained or used infrequently,vertical grow system with some identifying a chronic high user group and a few identifying groups that increased and decreased their use. The current study found that a HIV+ status was associated with membership in the decreaser, increaser and chronic high marijuana trajectory groups, a finding that suggests that overall HIV+ MSM in the MACS were more likely to use marijuana as compared to HIV− MSM. This finding is consistent with a number of studies reporting higher rates of marijuana use among HIV+ individuals as compared to HIV-uninfected populations. HIV+ individuals report using marijuana to alleviate symptoms related to HIV-infection as well as side effects of ART, although a substantial proportion of HIV+ individuals use marijuana recreationally. Approximately 16 % of the HIV+ men in this study reported decreasing their marijuana use over time. This pattern of decreasing substance use over time was recently observed in a study of trajectories of stimulant use among MACS participants. The authors also found that the men who decreased stimulant drug use reported significant reduction in risky sexual practices over time. Among the HIV+ MSM in this study, having a detectable HIV RNA over time was associated with increasing marijuana use among individuals in the increaser group, but not among the men in the decreaser or chronic high groups. Accordingly, we found that ART use over time was associated with decreasing marijuana use in the abstainer/infrequent and increaser groups. It is important to note that the assessment procedures used in this study make it difficult to ascertain that ART use preceded marijuana use. However, these findings provide some reassurance that there may not be an urgent need to intervene; however, there is a need to continue to study the long term effects of marijuana use on other health outcomes both in HIV+ and HIV− individuals.
In the data presented here, among the entire sample as well as HIV+ individuals, younger age was associated with membership in all marijuana trajectory groups and being nonHispanic, black was associated with membership in the decreaser and increaser groups. In addition, alcohol use, cigarette smoking, stimulants/recreational drug use, and depressive symptoms over time served to increase marijuana use within nearly all marijuana trajectory groups. This finding is consistent with previous studies that found substantial overlap between several types of drug use and other psychosocial health problems . Accordingly, any prevention approaches to mitigate these behaviors should not focus on one of these behaviors or conditions but must consider these co-occurring conditions holistically. Our study has some limitations which we highlight in order for some caution to be exercised in the interpretation of our study findings. We restricted our analysis to MACS participants who had at least 25 % or more study visits in order to estimate stable trajectory models. However, at baseline, those included in the study differed from those not included on a number of sociodemographic, clinical characteristics as well as use of substances including marijuana . Therefore, it is possible that different trajectories of marijuana use may have emerged if these participants had been included in our study. Furthermore, in the MACS, data on substance use was obtained via Audio Computer- Assisted Self-Interview . Although this method has demonstrated good accuracy in obtaining sensitive information such as drug use in studies of HIV+ individuals as well as the MSM samples, the data reported here related to substance use may be subject to social desirability bias and most likely an under reporting with a potential underestimation of the true trajectories of marijuana use. Related to this issue is the effect of other biases related to participation in a large ongoing cohort study such as the MACS, along with participant attrition due to drop outs and mortality, which may result in an underestimation of long-term marijuana use.
Indeed, in the current study, we found that men who increased their marijuana use and those with chronic high use over time were significantly more likely to die or to drop out during follow-up as compared to the abstainer/infrequent group. What this suggests is that the attrition in these groups may have precluded us from identifying what their patterns of marijuana use would have been if they had remained in the study. Also, participants in the MACS represent a highly cooperativecohort of MSM who have been retained in an ongoing cohort study; thus,cannabis grow equipment our findings may not be generalizable to the larger MSM population. Finally, the semi-parametric group based modeling approach used in this study has been criticized for its tendency to over identify trajectory groups. Accordingly, Nagin and Tremblay caution that groups extracted from the group-based trajectory models should be thought of as approximations of the more complex underlying reality of individual-level trajectories of a behavior; thus, reification of trajectory groups should be done with caution. In summary we used data from a large sample, with a long follow-up period, and utilized frequency measures of marijuana use to describe the natural history of marijuana use among HIV+ and HIV− MSM. Our study revealed different trajectories of use over time: with approximately 1 in 10 of the men emerging as chronic heavy users or increasing their use over time. Future investigations are needed determine whether long-term patterns of heavy use are associated with adverse consequences especially among HIV+ persons. Marijuana use among pregnant, breastfeeding, and reproductive-aged women has increased substantially in recent years . In the United States, national rates of use by pregnant women increased from 3.4% in 2002 to 7.0% in 2017 and particularly among younger women . In California, marijuana use by pregnant women increased from 4.2% in 2009 to 7.1% in 2016 and particularly for women ages 18 to 24, for whom use rates rose from 9.8 to 19% over this time . Comparable trends of increases in marijuana use, and especially for younger women, have been identified for new mothers and women of reproductive age in general . These increases fuel concerns about infant health consequences. The higher rates of use among young women, disadvantaged communities , and minority populations highlight the potential for disparities in infant health consequences due to maternal marijuana use. Marijuana use can be motivated by multiple psychosocial factors including peer use and efforts to cope with stress and negative affect . Beliefs about benefits and harms of marijuana use represent additional and malleable determinants of marijuana use. For example, marijuana use during pregnancy and while breastfeeding can be promoted by beliefs that it poses little or no risk to one’s infant and offers benefits such as reducing nausea or depression . Members of low-income, low-education, and minority populations, in addition to facing adversities that can exacerbate marijuana use , may be particularly likely to harbor such misperceptions due to inadequate access to health information and services .
The present study examines beliefs about the risks and benefits of marijuana use during pregnancy and breastfeeding held by residents in predominantly rural communities in California, a state that legalized recreational marijuana use in January 2018. Approximately 53.2% of the residents in this region identify as Hispanic or Latino/a/x and another 15.4% identify as a race/ethnicity other than non-Latino White . This culturally diverse region exhibits among the highest levels of income and health disparities in the U.S. . Language barriers, lack of landline phones, and low access to services in these communities contribute to their under-representation in studies using traditional survey techniques. This study employed survey methods designed to reach Latino, rural, and disadvantaged residents in this region.Growing evidence links marijuana use during pregnancy with adverse infant outcomes including stillbirth, miscarriage, preterm delivery, low birth weight, and need for neonatal intensive care . Emerging evidence also reveals its associations with deficits in attention and neurobehavioral functioning in infancy and childhood , poor intellectual performance and behavioral problems in childhood , and delinquent behaviors in adolescence . Research on how marijuana use by breastfeeding mothers affects infants is more limited, but emerging findings have stimulated concerns that it induces health harms. Its potential to affect infant physiological function is underscored by findings that tetrahydrocannabinol , the main psychoactive component, can be detected in breast milk 6 days to six weeks after use . A systematic review evaluating the safety of marijuana use while breastfeeding found that human and animal studies providing evidence supporting concerns about risks outnumber those finding no concerning evidence . In the absence of definitive evidence that it poses no health harms to infants, health organizations typically recommend a conservative approach of avoiding use while breastfeeding. The Academy of Breastfeeding Medicine also recommends that providers counsel pregnant and breastfeeding women and their family members on the risks and uncertainties surrounding marijuana use in breastfeeding . These guidelines tend to be vague and tentative about risks which, although in keeping with current scientific evidence, could limit their persuasiveness and especially for recipients with opposing beliefs about the safety and benefits of maternal marijuana use. Consultations with local health organizations have identified concerns about the public’s misperceptions regarding safety and the lack of evidence-based guidelines that enable pregnant and breastfeeding women to make informed decisions about marijuana use .Beliefs that a substance poses significant health risks are protective factors against its use and evidence, while limited, links low risk perceptions of cannabis use with substantially higher use rates among pregnant women , suggesting that health communications and guidelines that enhance beliefs in the risks of marijuana use during pregnancy or while breastfeeding could discourage their use during these times. In a sample of women receiving prenatal care, declines in marijuana use were attributed to having received educational materials on cessation of marijuana use during pregnancy . Importantly, however, acceptance of this health information will be influenced by the existing beliefs and risk perceptions held by the recipients . Little is known about how much women, their romantic partners and family members, and adults in their broader social networks hold beliefs that run counter to these guidelines and so may be resistant to accepting these recommendations. Understanding the beliefs held by romantic partners, family members, and members of one’s social network is important because these people can exert considerable influence on women’s health choices in general , during pregnancy, and while breastfeeding . Thus, understanding the beliefs held by community members more broadly is essential for identifying common misconceptions and social groups who tend to harbor them in order to develop health communications and campaigns that promote accurate beliefs for those who influence marijuana use decisions of pregnant and breastfeeding women.