Untangling the impact of sexual abuse on HIV risk behaviors among youths in foster care

Racial and Ethnic Disparities in the Physical Health Outcomes of Children in Foster Care: A Systematic Review

Children of color-especially Black and Indigenous children-are disproportionately overrepresented in foster care and experience barriers in accessing services and receiving physical and behavioral healthcare compared to their White counterparts. Although racial disparities in mental health outcomes of children in foster care have been examined systematically, less is known about racial disparities in their physical health outcomes. This systematic review aimed to examine disparities in physical health outcomes (i.e., general health, developmental delays and disability, chronic illness, health-compromising behaviors, all-cause mortality) of children in foster care by their race and ethnicity (PROSPERO ID: CRD42021272072). Systematic literature searches were conducted in PubMed, EMBASE, PsycINFO, CINAHL, Cochrane Library, and Psychology and Behavioral Sciences Collection. Of the 6,102 unique studies identified, 24 met inclusion criteria: peer-reviewed journal article; published from 1991 to 2021; written in English; involved children in the U.S. foster care system; children were primarily in family-based placements; included health outcomes; included children's race and ethnicity; conducted quantitative analyses; and had an observational study design. There was limited evidence to suggest racial disparities among physical health domains examined, in part, due to the small number of studies, variability across study measures and designs, how race and ethnicity were categorized, and how related results were reported. Research that disaggregates results by more nuanced race and ethnicity categories, goes beyond including race and ethnicity as control variables, and uses more robust study designs to understand where racial disparities lie is necessary to inform practice and policy efforts to attain race and health equity in child welfare.

What happens when we ask? A phenomenological focus group on HIV prevention and sexual health education among emancipated foster care youth

Youth of color who have recently been emancipated from foster care are among the most vulnerable group at risk for having poor sexual health outcomes. It is essential for researchers to understand how emancipated foster care youth receive messages about safe sex and HIV/STI prevention in order to tailor health promotion activities for this group. This study presents a strengths-based view of emancipated foster care youth of color who developed an empowering, arts-based campaign to prevent HIV in their community using Youth Participatory Action Research (Y-PAR) methods. The project was led by 10 emancipated foster care youth who participated in two focus groups that centered on understanding their knowledge of HIV. Five major themes emerged from the focus group. Implications for researchers include incorporating safe spaces for youth to develop ideas that can result in empowering activities relating to prevention.

Modeling changes in adolescent health risk behaviors approaching and just after the time of emancipation from foster care

BACKGROUND

Emancipated foster youth frequently engage in behaviors that contribute to poor health. Whether health risk behaviors increase following emancipation or are established while in foster care remains unclear.

OBJECTIVE

This secondary data analysis examined substance use and attitudes toward sexual risk behaviors to understand continuity in risk behaviors among foster youth before emancipation and following emancipation.

PARTICIPANTS AND SETTING

Youth ages 16-20 (N = 151) who had been in foster care for at least 12 months and were expected to emancipate were recruited. The urban county where the study was conducted allowed youth to remain in foster care until 21 years of age.

METHODS

Participants completed surveys assessing substance use and attitudes toward sexual risk behaviors at baseline, 6 and 12 months. Multilevel models estimated trajectories of health behaviors and attitudes, with emancipation timing as the primary predictor. Individual and child welfare characteristics were included as covariates.

RESULTS

Substance use did not change with emancipation (B_s = 0.01, p = 0.81) and positive attitudes about risky sexual behavior significantly decreased as youth approached emancipation (B_s = 1.67, p < 0.01). Placement instability and adversity were not associated with either outcome (ps > 0.08). Females reported more positive attitudes about higher-risk sexual behavior than males (B = 3.09, p < 0.01) and less substance use (B = -1.15, p = 0.03).

CONCLUSIONS

Substance use and attitudes about sexual risk behaviors are established before emancipation; interventions prior to emancipation are necessary to improve health outcomes.

Prevalence and Correlates of Forced Sex as a Self-Reported Mode of HIV Acquisition Among a Cohort of Women Living With HIV in Canada

Gender-based violence (GBV) is a global epidemic associated with increased HIV exposure. We assessed the prevalence and correlates of HIV acquisition via forced sex among women living with HIV (WLWH) in Canada. Baseline questionnaire data were analyzed for WLWH (≥16 years) with data on self-reported mode of HIV acquisition, enrolled in a community-based cohort study in British Columbia, Ontario, and Québec. We assessed forced sex (childhood, adulthood) as a self-reported mode of HIV acquisition. Of 1,330 participants, the median age was 42 (interquartile range [IQR] = 35-50) years; 23.5% were Indigenous, 26.3% African/Caribbean/Black, 43% White, and 7.2% of Other ethnicities. Forced sex was the third dominant mode of HIV transmission at 16.5% (n = 219; vs. 51.6% consensual sex, 19.7% sharing needles, 5.3% blood transfusion, 3.8% perinatal, 1.3% contaminated needles, 0.4% other, 1.6% do not know/prefer not to answer). In multivariable analyses, significant correlates of HIV acquisition from forced versus consensual sex included legal status as a landed immigrant (adjusted odds ratio [aOR] = 1.99; 95% confidence interval [CI] = [1.12, 3.54]) or refugee (aOR = 3.62; 95% CI = [1.63, 8.04]) versus Canadian citizen; African/Caribbean/Black ethnicity versus Caucasian (aOR = 2.49; 95% CI = [1.43, 4.35]), posttraumatic stress disorder symptoms (aOR = 3.00; 95% CI = [1.68, 5.38]), histories of group home residence (aOR = 2.40; 95% CI = [1.10, 5.23]), foster care (aOR = 2.18; 95% CI = [1.10, 4.34]), and having one child relative to having three or more children (aOR = 0.52; 95% CI = [0.31, 0.89]). GBV must be considered a distinct HIV risk factor; forced sex is a significant underrecognized risk factor and mode of women's HIV acquistion. Public health reporting systems can separate consensual and forced sex in reporting modes of HIV acquisition. Practitioners can engage in screening practices to meet client needs.

"Strap up:" Sexual socialization and safer sex practices among African American youth in foster care

Adolescent sexual health is often reflected through a problem-oriented lens. This serves to reinforce prevailing sexual scripts and cultural images of disenfranchised youth. Very little is known about the support young people in foster care, particularly youth of color, need to stay sexually healthy and safe. This article presents data on the sources and types of sexual socialization experiences that supported African American transitional age youth in foster care to protect against sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). Eighteen African American participants (18 to 21-years old) who reported condom use in two quantitative interviews were selected to participate in a qualitative interview. A mapping exercise and thematic analyses were used to identify the participants' sources of support and sexual socialization experiences. The study's findings indicated the youth had a combination of informal and formal sources that conveyed four types of STI/HIV prevention messages: Effective, Affective, Affinity, & Tangible. The majority of the participants (83%) received all four types of STI/HIV prevention messages from adult, partner and/or peer sources. Sources who motivated the participants the most to protect against STIs/HIV had a strong relationship with the youth and communicated openly about safer sex practices. Results of this study provide implications for future research as well as indications for practice that may be incorporated into training for child welfare practitioners, foster parents, kinship caregivers, and others who encounter youth in foster care.

Sexually Transmitted Infections In A Sample Of At-Risk Youth: Roles Of Mental Health And Trauma Histories

Little is known about whether there are specific subpopulations of youth with known problem behaviors that are more likely to engage in sexual risk behaviors. This study's sample (n=4,117) was drawn from a larger longitudinal administrative data, consisting of young adults with child abuse and/or poverty histories and records of some form of high-risk behavior or mental health diagnosis during adolescence. A cluster-controlled, logistic regression resulted in eleven statistically significant relationships. Youth treated for a mental health disorder and experienced multiple forms of abuse were more likely to be treated for Sexually Transmitted Infections (STIs). Youth who were delinquent,, treated for substance abuse and had substance use related offenses were less likely to be treated for STIs. Youth treated for STIs were more likely to be identified through mental health systems or child protective services system than through known delinquent behaviors. Health care providers treating youth for STIs should explore the possible role of mental health and trauma histories.

The impact of substance use, sexual trauma, and intimate partner violence on sexual risk intervention outcomes in couples: a randomized trial

BACKGROUND

Few HIV prevention interventions focus on sexual risk reduction as mutual process determined by couple members, though risk behaviors are inter-dependent.

PURPOSE

This trial examined the impact of substance use, history of sexual trauma, and intimate partner violence on sexual risk associated with participation in a risk reduction intervention.

METHODS

HIV seroconcordant and serodiscordant multicultural couples in Miami, Florida (n = 216) were randomized to group (n = 112) or individual (n = 104) couple-based interventions.

RESULTS

Group intervention participants increased condom use in couples in which women had a history of sexual trauma [F(2,221) = 3.39, p = 0.036] and by partners of alcohol users. History of sexual trauma was a determinant of conflict resolution, predicting negative communication and intimate partner violence.

CONCLUSIONS

Results emphasize the need for group sexual risk reduction interventions targeting sexual trauma, partner violence, and substance use among HIV seroconcordant and serodiscordant couples.

Victimization and sexual risk behavior in young, HIV positive women: exploration of mediators

In this study we explore associations between child and adult victimization and sexual risk behavior in 118 young, HIV positive women. Prior research has demonstrated associations between victimization and engagement in sexual risk behavior. Victimization sequelae can include disrupted assertiveness and communication, as well as increased association with risky partners, both of which are also linked with engagement in sexual risk behavior. Thus, we propose a model wherein victimization is linked to sexual risk behavior through two mediating pathways, sexual communication and affiliation with risky partners. We also examine the moderating effects of the presence of an anxiety or depressive disorder on the path from child to adult victimization. Results suggested that adult victimization was associated with unprotected sex with a main partner; however, this association was mediated by less sexual communication and having a risky partner. Trends toward significance were found for depression and anxiety as a moderator of the relationship between child and adult victimization. Child victimization did not have direct effects on unprotected sex. Implications for secondary prevention of HIV and healthy intimate relationships are discussed.

Associations between child sexual abuse and negative sexual experiences and revictimization among women: does measuring severity matter?

Women with histories of child sexual abuse (CSA) are more likely than those without such experiences to report a variety of negative sexual outcomes. This study examines the explanatory power of a CSA summed composite versus dichotomous (presence/absence) measurement in predicting a comprehensive negative sexual behavior outcome. Study participants were obtained from a community based sample examining women's sexual decision-making. The continuous CSA measurement reflects cumulative histories of CSA through a composite score capturing abuse specific characteristics. Using a cross-validation approach, the sample (n=835) was randomly split and the explanatory power of each measure was examined through a series of multiple linear regressions comparing model fit indexes and performing a formal likelihood ratio test of one model against another. All CSA measures explained a similar percentage of variance but overall the CSA summed composite explained the data significantly better in terms predicting negative sexual experiences and revictimization than a binary measure as demonstrated with the likelihood ratio test. The results were replicated by cross-validating the predictive power of the CSA composite score between the split samples. Consistency of CSA regression estimates for the summed composite between training and validation samples were also confirmed. Given the superiority of the CSA summed composites over the binary variable, we recommend using this measure when examining associations between CSA histories and negative sexual experiences and revictimization.

Preventing internalizing and externalizing problems in girls in foster care as they enter middle school: impact of an intervention

Girls in foster care have been shown to be at risk for emotional and behavioral problems, especially during the preadolescent and adolescent years. Based on these findings and on the lack of research-based preventive interventions for such youths, the current study examined the impact of an intervention targeting the prevention of internalizing and externalizing problems for girls in foster care prior to middle school entry. Study participants included 100 girls in state-supported foster homes who were randomly assigned to an intervention condition or to a control condition (foster care services as usual). The intervention girls were hypothesized to have fewer internalizing problems, fewer externalizing problems, and more prosocial behavior at 6-months post-baseline compared to the control girls. The results confirmed the hypotheses for internalizing and externalizing problems, but not for prosocial behavior. Limitations and future directions are discussed.

Sexual self-schemas of female child sexual abuse survivors: relationships with risky sexual behavior and sexual assault in adolescence

Childhood sexual trauma has been demonstrated to increase survivors' risk for engaging in unrestricted sexual behaviors and experiencing adolescent sexual assault. The current study used the sexual self-schema construct to examine cognitive representations of sexuality that might drive these behavioral patterns. In Study 1 (N = 774), we attempted to improve the content validity of the Sexual Self Schema Scale for child sexual abuse (CSA) survivors, introducing a fourth sexual self-schema factor titled the "immoral/irresponsible" factor. In Study 2 (N = 1150), the potential differences in sexual self-views, as assessed by the four sexual self-schema factors, between CSA survivors and non-victims were explored. In addition, Study 2 evaluated how these sexual self-schema differences may contribute to participation in unrestricted sexual behaviors and risk for sexual assault in adolescence. Results indicated that a history of CSA impacted the way women viewed themselves as a sexual person on each of the four factors. CSA survivors were found to view themselves as more open and possessing more immoral/irresponsible cognitions about sexuality as compared to women who did not have a CSA history. In addition, the CSA survivors endorsed less embarrassment and passionate/romantic views of their sexual selves. The interaction of CSA severity and the sexual self-schemas explained variance in adolescent sexual assault experiences above and beyond the severity of CSA history and participation in risky sexual behaviors. The findings suggest that sexual self-views may serve to moderate the relationship between CSA and adolescent sexual assault. Implications of these findings and directions for future research are discussed.

Sexual risk-taking among high-risk urban women with and without histories of childhood sexual abuse: mediating effects of contextual factors

This study investigated the mechanisms of risk for urban women at high risk for HIV with and without childhood sexual abuse histories. Childhood sexual abuse survivors reported more unprotected intercourse and sexually transmitted infections (STIs). The association of STI locus of control with frequency of unprotected sex was fully mediated by being intoxicated during sex and engaging in sex work, whereas the association between relational control and unprotected sex was not mediated by contextual factors for the childhood sexual abuse group. The mechanisms of risk are different for those with divergent childhood sexual abuse histories and thus interventions should be developed to educate women with a history of childhood sexual abuse about ways to avoid revictimization, particularly within a context of poverty, prostitution, and drug use.

Sexual abuse and sexual risk behavior: beyond the impact of psychiatric problems

OBJECTIVE

This study examined the association between sexual abuse (SA) and sex risk in girls and boys placed in alternative and therapeutic school settings while controlling for psychiatric problems.

METHOD

Adolescents were recruited from alternative and therapeutic schools. Youth completed audio computer-assisted self-interviews assessing childhood abuse, sexual behaviors, sexual attitudes, and psychiatric symptoms.

RESULTS

Of the 162 youth with available data, 23% reported a moderate or severe SA history. After controlling for gender and the presence of a psychiatric diagnosis, youth with a SA history were significantly more likely to have engaged in sex, had sex in the last 90 days, and engaged in unprotected sex. Adolescents with a history of SA also endorsed fewer advantages of using condoms.

CONCLUSIONS

SA is uniquely associated with sexual behavior and attitudes even when adjusting for the presence of a psychiatric diagnosis. These data have implications for interventions for those with SA histories.

Sexual Risk Behaviors Among Youth in the Child Welfare System

This study uses data from the National Survey of Child and Adolescent Well-Being (NSCAW) to provide estimates of sexual risk behaviors for 877 youth, age 11-14 at baseline, in the child welfare system. It examines the association between baseline psychosocial risk and protective factors on engagement in sexual risk behaviors after 36 months. It further compares rates of sexual risk behaviors between youth placed in out-of-home care and those who remained with their biological family. Key findings include a high rate of pregnancy, a high percentage of youth who initiated sexual activity at or before age 13 as well as a limited role of protective factors in moderating sexual risk behaviors. A history of placement into out-of-home care is not significantly associated with greater engagement in sexual risk behaviors. Implications for intervention development and child welfare policy for this population are discussed.

Psychiatric diagnosis and antiretroviral adherence among adolescent Medicaid beneficiaries diagnosed with human immunodeficiency virus/acquired immunodeficiency syndrome

Research on adults with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) has suggested that psychiatric and substance abuse comorbidities are prevalent in this population, and that these may sometimes be associated with use of antiretroviral therapy (ART) and adherence. For adolescents with HIV/AIDS, much less is known about patterns of mental health comorbidity, and even fewer data are available that compare them to socioeconomically comparable youth without HIV/AIDS. Using medical and pharmacy data from 1999 to 2000 Medicaid claims (Medicaid Analytic Extract) from 4 states for beneficiaries aged 12 to 17 years, we identified 833 youth under care for HIV/AIDS meeting study criteria within the HIV/AIDS group, receipt of ART was less likely for youth who had diagnoses of substance abuse, conduct disorders, or emotional disorders than for others. Once ART was initiated, adherence did not significantly differ between adolescents living with a psychiatric condition, and those who were not, with the exception of an association between conduct disorder and lower adherence. Among those with HIV/AIDS, ART use and adherence were more common among youth with higher rates of service use, regardless of psychiatric status. Associations between race and adherence varied by gender: compared with their white counterparts, minority girls had lower, and minority boys had higher adherence.

History of childhood sexual abuse and HIV risk behaviors in homosexual and bisexual men

OBJECTIVES

We examined the prevalence and frequency of childhood sexual abuse and their association with sexual risk among a sample of gay and bisexual men. Methods. Cross-sectional data were collected by survey from randomly selected gay and bisexual men who attended the 1997 and 1998 Minneapolis/St. Paul Gay, Lesbian, Bisexual, and Transgender Pride Festivals. Data included demographics, sexual activity, history of childhood sexual abuse, HIV status, history of sexually transmitted infection, use of sex-related drugs (such as crack, cocaine, Ecstasy, amyl nitrate, crystal methamphetamine, and Special K), and history of exchanging sex for payment. Results. childhood sexual abuse was reported by 15.5% of the survey respondents (n = 134). Those who reported experiencing abuse regularly were more likely to (1) be HIV positive, (2) have exchanged sex for payment, and (3) be a current user of sex-related drugs. Neither unsafe sex nor sexually transmitted infections were associated with childhood sexual abuse.

CONCLUSIONS

These findings show that more than 1 in 7 gay and bisexual men in a non-clinical, festival-based setting were victims of childhood sexual abuse and that childhood sexual abuse was associated with alarmingly high rates of men who were HIV infected and antecedent risk behaviors.

Child abuse and AIDS-related knowledge, attitudes and behavior among adolescents in Zambia

OBJECTIVE

To research the correlation between physical and sexual abuse by family members and AIDS-related knowledge, attitudes, self-efficacy and behavior among urban and rural adolescents in Zambia.

SAMPLE

The sample comprises 3,360 adolescents, aged 10-19, from urban and rural Zambia; 2,160 of them attended school, while 1,200 of them did not.

MEASURES

Standardized scales were utilized to assess AIDS-related knowledge, attitudes, and self-efficacy. In addition, the adolescents reported the extent of their engagement in various high-risk behaviors and their lifetime experience of being sexually or physically abused.

RESULTS

As the level of abuse experienced by the adolescents increased, their level of knowledge about HIV/AIDS, tendency to hold positive attitudes toward prevention, and level of self-efficacy regarding HIV/AIDS prevention decreased. Most importantly, when controlling for socio-demographic variables, findings indicate that past abuse was a key factor predicting participation in high-risk behaviors associated with HIV infection.

CONCLUSION

Physical and sexual abuse of adolescents in Zambia is significantly related to HIV risk behaviors. Future studies should investigate which factors mediate between the experience of abuse and the tendency to engage in risky behaviors.

Identification of high-risk behaviors among victimized adolescents and implications for empirically supported psychosocial treatment

An adolescent's possible response to being the victim of interpersonal violence is not limited to posttraumatic stress disorder and depression but may also involve a host of developmental effects, including the occurrence of high-risk behaviors that may have a significant and negative impact on the adolescent's psychological and physical health. Identifying such high-risk behaviors, understanding their possible link to a previous victimization incident, and implementing interventions that have been demonstrated to reduce such behaviors may help decrease potential reciprocal interactions between these areas. Clinicians in psychiatric practice may be in a unique position to make these connections, since parents of adolescents may perceive a greater need for mental health services for youth engaging in problematic externalizing behaviors than for those displaying internalizing symptoms. In this article, the authors first describe high-risk behaviors, including substance use, delinquent behavior, risky sexual behaviors, and self-injurious behaviors, that have been linked with experiencing interpersonal violence. They then review empirically based treatments that have been indicated to treat these deleterious behaviors in order to help clinicians select appropriate psychosocial interventions for this population. Recommendations for future research on the treatment of high-risk behaviors in adolescents are also presented.

Adolescent girls' offending and health-risking sexual behavior: the predictive role of trauma

Several studies have highlighted high levels of risk for girls who have been exposed to traumatic experiences, but little is known about the exact relationship between traumatic experiences and problems with delinquency and health-risking sexual behavior (e.g., precipitory and/or exacerbatory roles). However, numerous short- and long-term detrimental effects have been linked to trauma, delinquency, and health-risking sexual behavior. The utility of diagnostic and experiential trauma measures in predicting the greatest risk for poor outcomes for delinquent girls was examined in this study. Results indicate that the experiential measures of trauma (cumulative and composite trauma scores) significantly predicted adolescent offending and adolescent health-risking sexual behavior, whereas the diagnostic measures of trauma (full and partial diagnostic criteria) did not.

Risk factors for alcohol and marijuana use among adolescents in foster care

This study examined the influences of individual and social risk factors on alcohol and marijuana use among a sample of foster care adolescents. Data were collected through baseline structured interviews with 320 adolescents (aged 15-18 years) who resided in foster care placements and participated in a larger evaluation study of an independent living program. Approximately 40% of the adolescents reported alcohol use, 36% reported marijuana use, and 25% reported both alcohol and marijuana use during the 6 months prior to the interview. Final logistic regression models indicated that having friends who used marijuana and other substances and having skipped school remained most predictive of using alcohol, marijuana, or both alcohol and marijuana. Recommendations for substance abuse prevention and treatment for these vulnerable adolescents are proposed.

Severity of child sexual abuse, post- traumatic stress and risky sexual behaviors among HIV-positive women

Child sexual abuse (CSA) has been shown to enhance risk for HIV infection and other adverse outcomes. However, most studies examine the effects of a single incident of CSA rather than the full burden of abuse over the life span in predicting these adverse outcomes. A multi-dimensional approach was used in this study to examine the severity of abuse as a predictor of post-traumatic stress, depression, sexual symptoms, and risky sexual behaviors in a multi-ethnic sample of 147 HIV-positive women. Multivariate models indicated that experiencing both intrafamilial and extrafamilial CSA, adult sexual abuse (ASA) and Latina ethnicity predicted PTSD symptoms. ASA also predicted sexual trauma symptoms. Also, CSA and adult re-victimization contributed independently to risk for PTSD and sexual trauma symptoms, but not for risky sexual behaviors. The results support the need for interventions for HIV-positive women that address the full burden of abuse experienced and its sequelae.

Signs of resilience in sexually abused adolescent girls in the foster care system

In a sample of 99 sexually abused adolescent girls in the foster care system (64% in congregate living situations and 36% in family/foster care homes), nearly half were psychologically functioning well despite having experienced moderate-to-severe emotional, physical, and sexual abuse. It was hypothesized that these girls with resilient trajectories would differ from the currently symptomatic girls on several protective factors: education, future orientation, family support, peer influence, and religion. The results revealed that the girls with resilient trajectories were significantly more certain of their educational plans and optimistic about their future and had more positive peer influences.

Sexual and physical victimization as predictors of HIV risk among felony drug offenders

Injection and other drug use and high-risk sexual behaviors put criminal offenders at increased risk for HIV infection. Studies in other populations, especially females, have found that a history of sexual or physical victimization increases engagement in HIV-risk behaviors, and drug-involved offenders have high rates of such prior victimization. However, there has been little research among male offenders. In a sample of 247 male felony drug offenders in New York City, prior sexual victimization was related to a higher number of sex partners and lower proportion of protected sex acts in the 30 days before arrest. Prior physical abuse was related to cocaine injection, but not heroin injection or high-risk sex behaviors. These results suggest a complex relationship between sexual and physical abuse and HIV risk among male offenders. Assessing for specific prior abuse histories of offenders and providing targeted interventions may be useful for developing more effective primary and secondary HIV prevention services for this high-risk population.

Childhood sexual abuse and age at initiation of injection drug use

OBJECTIVES

We examined the relation between childhood sexual abuse and injection drug use initiation among young adult injection drug users.

METHODS

We used mixed effect linear models to compare age at first injection among 2143 young injection drug users by first sexual abuse age categories.

RESULTS

The participants were predominantly male (63.3%) and White (52.8%). Mean age and age at first injection were 23.7 and 19.6 years, respectively; 307 participants (14.3%) reported childhood sexual abuse. After adjustment for gender, race/ethnicity, noninjection drug use before first injection drug use, and recruitment site, childhood sexual abuse was independently associated with younger age at first injection.

CONCLUSIONS

Childhood sexual abuse was associated with earlier initiation of injection drug use. These data emphasize the need to integrate substance abuse prevention with postvictimization services for children and adolescents.

Gender differences in the context of sex exchange among individuals with a history of crack use

Although sex exchange among crack users is associated with risky sexual behavior, research suggests that there is a subgroup of crack users who do not engage in high-risk sex exchange. The purpose of this study is to understand differences among individuals with a history of crack use who have and have not engaged in sex exchange; and to better understand gender differences in the context of sex exchange. The study sample included 148 male (64.2% reported sex exchange) and 149 female heterosexual individuals with a history of crack use (59.1% reported sex exchange). Results suggest that HIV prevention interventions should incorporate gender specific information related to sex exchange for heterosexual crack users. Future research is needed to address the gap in understanding the transition into sex exchange practices for heterosexual male and female drug users.

Women, sex, and HIV: social and contextual factors, meta-analysis of published interventions, and implications for practice and research

This article is focused on examining social and contextual factors related to HIV-risk behavior for women. Specifically, this article has three main purposes: to review the literature on selected social and contextual factors that contribute to the risk for the heterosexual transmission of HIV and AIDS, to review and conduct a meta-analysis of HIV-prevention interventions targeting adult heterosexual populations, and to suggest future directions for HIV-prevention intervention research and practice. Results suggest that the HIV-prevention interventions reviewed for this article had little impact on sexual risk behavior, that social and contextual factors are often minimally addressed, and that there was a large gap between research and the practice of HIV-prevention intervention.