The risk of HIV infection in a national sample of women with injection drug-using partners

A Brief Assessment for HIV Risk: The TCU HVHP Form

Targeted HIV screens may help identify some risk-related concerns of drug-using offenders. The present study describes the Texas Christian University HIV/Hepatitis Risk Assessment (TCU HVHP) form, a 19-item self-report instrument measuring HIV and hepatitis risks based on a sample (N = 1,056) of offenders in eight prisons. Principal components analysis indicated four scales (Injection Risk, Condom Attitudes, Sex Risk, and AIDS Concern) with reliable psychometric properties with coefficient α reliabilities ranging from .72 to .88. Concurrent validities indicated the four scales were related to motivation for treatment, level of drug use, psychosocial functioning, and criminal thinking, although the patterns varied by gender. The TCU HVHP Form should be attractive to programs needing a brief assessment measuring HIV risk behaviors, attitudes toward condom use, and concerns about acquiring and transmitting HIV.

Gender Differences in HIV Risk Behaviors Among Persons Involved in the U.S. Criminal Justice System and Living with HIV or at Risk for HIV: A "Seek, Test, Treat, and Retain" Harmonization Consortium

The U.S. female criminal justice (CJ) population is rapidly growing, yet large-scale studies exploring gender-specific HIV risk behaviors in the CJ population are lacking. This analysis uses baseline data on adults with a CJ history from eight U.S. studies in an NIH-funded "Seek, Test, Treat, Retain" harmonization consortium. Data were collected using a standardized HIV risk behavior assessment tool and pooled across studies to describe participants' characteristics and risk behaviors. Multilevel mixed-effects logistic regression models were used to test for gender-based behavior differences. Among 784 HIV-positive (21.4% female) and 5521 HIV-negative (8.5% female) participants, HIV-positive women had higher odds than HIV-positive men of engaging in condomless sexual intercourse (AOR 1.84 [1.16-2.95]) with potentially sero-discordant partners (AOR 2.40 [1.41-4.09]) and of sharing injection equipment (AOR 3.36 [1.31-8.63]). HIV risk reduction interventions targeting CJ-involved women with HIV are urgently needed as this population may represent an under-recognized potential source of HIV transmission.

Gender Differences in HIV Sexual Risk Behaviors Among Clients of Substance Use Disorder Treatment Programs in the U.S

This study examined differences in sexual risk behaviors by gender and over time among 1281 patients (777 males and 504 females) from 12 community-based substance use disorder treatment programs throughout the United States participating in CTN-0032, a randomized control trial conducted within the National Drug Abuse Treatment Clinical Trials Network. Zero-inflated negative binomial and negative binomial models were used in the statistical analysis. Results indicated significant reductions in most types of sexual risk behaviors among substance users regardless of the intervention arms. There were also significant gender differences in sexual risk behaviors. Men (compared with women) reported more condomless sex acts with their non-primary partners (IRR = 1.80, 95 % CI 1.21-2.69) and condomless anal sex acts (IRR = 1.74, 95 % CI 1.11-2.72), but fewer condomless sex partners (IRR = 0.87, 95 % CI 0.77-0.99), condomless vaginal sex acts (IRR = 0.83, 95 % CI 0.69-1.00), and condomless sex acts within 2 h of using drugs or alcohol (IRR = 0.70, 95 % CI 0.53-0.90). Gender-specific intervention approaches are called for in substance use disorder treatment.

Male Condom Use by Type of Relationship following an HIV Intervention among Women Who Use Illegal Drugs

Predictors of increased male condom use are investigated following a recent, gender-specific HIV intervention among African-American women. Data were analyzed from 138 women (aged 18 to 59), recruited from inner-city Atlanta (Georgia, U.S.) neighborhoods. Predictors of condom use with steady and casual paying partners were examined separately. Increased condom use with steady partners was associated with drug-using status, intervention assignment, sexual relationship characteristics, age at first condom use, and HIV testing history. Condom use with casual paying partners was associated with having sex while high and the frequency of crack cocaine use. Personalized norms regarding condom use were not salient factors in predicting increased rates of condom use with either partner type. Findings indicate the continued need to consider sex in the context of drug use, and reveal the importance of measuring such influences and all antecedents of condom use separately for steady versus casual sexual relationships.

Provision of onsite HIV Services in Substance Use Disorder Treatment Programs: A Longitudinal Analysis

The provision of HIV education and testing in substance use disorder (SUD) treatment programs is an important public health strategy for reducing HIV incidence. For many at-risk individuals, SUD treatment represents the primary point of access for testing and receiving HIV-related services. This study uses two waves of nationally representative data of 265 privately-funded SUD treatment programs in the U.S. to examine organizational and patient characteristics associated with offering a dedicated HIV/AIDS treatment track, onsite HIV/AIDS support groups, and onsite HIV testing. Our longitudinal analysis indicated that the majority of treatment programs reported providing education and prevention services, but there was a small, yet significant, decline in the number of programs providing these services. Programs placed more of an emphasis on providing information on the transmission of HIV rather than on acquiring risk-reduction skills. There was a notable and significant increase (from 26.0% to 31.7%) in programs that offered onsite HIV testing, including rapid HIV testing, and an increase in the percentage of patients who received testing in the programs. Larger programs were more likely to offer a dedicated HIV/AIDS treatment track and to offer onsite HIV/AIDS support groups, while accredited programs and programs with a medical infrastructure were more likely to provide HIV testing. The percentage of injection drug users was positively linked to the availability of specialized HIV/AIDS tracks and HIV/AIDS support groups, and the percentage of female clients was associated with the availability of onsite support groups. The odds of offering HIV/AIDS support groups were also greater in programs that had a dedicated LGBT track. The findings suggest that access to hospitals and medical care services is an effective way to facilitate adoption of HIV services and that programs are providing a needed service among a group of patients who have a heightened risk of HIV transmission. Nonetheless, the fact that fewer than one third of programs offered onsite testing, and, of the ones that did, fewer than one third of their patients received testing, raises concern in light of federal guidelines.

'Women at risk': the health and social vulnerabilities of the regular female partners of men who inject drugs in Delhi, India

Needle and syringe sharing is common among people who inject drugs and so is unprotected sex, which consequently puts their sex partners at risk of sexually transmitted infections (STIs) including HIV and other blood-borne infections, like hepatitis. We undertook a nested study with the regular female partners of men who inject drugs participating in a longitudinal HIV incidence study in Delhi, India. In-depth interviews were conducted with female partners of 32 men. The interviews aimed to gather focused and contextual knowledge of determinants of safe sex and reproductive health needs of these women. Information obtained through interviews was triangulated and linked to the baseline behavioural data of their partner (index men who injected drugs). The study findings illustrate that women in monogamous relationships have a low perception of STI- and HIV-related risk. Additionally, lack of awareness about hepatitis B and C is a cause of concern. Findings also suggest impact of male drug use on the fertility of the female partner. It is critical to empower regular female partners to build their self-risk assessment skills and self-efficacy to negotiate condom use. Future work must explore the role of drug abuse among men who inject drugs in predicting fertility and reproductive morbidity among their female partners.

Reducing risky relationships: a multisite randomized trial of a prison-based intervention for reducing HIV sexual risk behaviors among women with a history of drug use

Women involved in the criminal justice system, particularly those with a history of drug use, are at elevated risk of HIV infection, yet few HIV prevention interventions have been tailored for delivery to incarcerated women. Drawing on the Relational Model, the Reducing Risky Relationships for HIV (RRR-HIV) intervention was developed and evaluated in a multisite randomized clinical trial. Women with weekly drug use prior to incarceration (n = 444) who were incarcerated within correctional institutions in four states were randomized to (1) the RRR-HIV intervention consisting of an HIV educational video, five group sessions, and one postrelease booster session or (2) a control condition consisting of the HIV educational video. The RRR-HIV intervention combined didactic and interactive content regarding seven "thinking myths" about intimate relationships that may result in decisions to engage in risky sexual behaviors. Data were collected while women were still incarcerated and approximately 90 days following release from prison by trained interviewers. A negative binomial regression (NBR) model of unprotected sexual behaviors at the 90-day follow-up indicated that RRR-HIV participants reported fewer unprotected sexual behaviors than women in the control condition once the analysis was adjusted for study site. Future studies should examine the sustainability of the RRR-HIV intervention's effect on risk reduction. Implementation research is needed to determine whether delivery of this intervention by correctional staff or peers, rather than research staff, yields similar reductions in unprotected sexual behaviors.

Patient characteristics and availability of onsite non-rapid and rapid HIV testing in US substance use disorder treatment programs

Racial and ethnic minorities and injection drug users (IDUs) are at increased risk of HIV infection. However, the associations between these caseload characteristics and the availability of onsite HIV testing in substance use disorder treatment programs are unknown. This study uses data collected in 2008-2009 from 198 program administrators of treatment programs participating in the National Institute on Drug Abuse's Clinical Trials Network to address this gap in the literature. Results show positive associations between the percentages of African American, Hispanic, and IDU patients and the odds of offering non-rapid onsite HIV testing versus no onsite testing. The associations between racial/ethnic composition and the availability of rapid HIV testing were more complicated. These findings suggest that many programs are responding to the needs of at-risk populations. However, programs and their patients may benefit from greater adoption of rapid testing which is less costly and better ensures that patients receive their results.

Substance use and high risk sexual behaviors among women in psychosocial outpatient and methadone maintenance treatment programs

OBJECTIVES

The purpose of the present study was to assess the association between substance use/diagnosis and sexual risk behaviors among women enrolled in both psychosocial outpatient (PS) and methadone maintenance (MM) treatment and involved in a HIV prevention intervention study within the National Institute for Drug Abuse Clinical Trials Network.

METHODS

515 sexually active women reported on unprotected sexual occasions (USO), anal sex, sex trading, sex with drug occasions, and multiple male sex partners at the baseline assessment.

RESULTS

Within the PS sample, cocaine use diagnosis was associated with more than twice the risk of having multiple partners, trading sex for drugs, having anal sex, or having sex with drugs; alcohol or opioid use diagnosis was associated with fewer risk behaviors. Within the MM sample, cocaine use, alcohol use and opiate use diagnoses were each associated with one to two risk behaviors. Associations between sexual risk and substance using days were less frequent in both samples.

CONCLUSIONS

These findings highlight the need for integration of HIV sexual prevention interventions that address the relationship between sexual risk behavior and substance use diagnoses into substance abuse treatment programs.

Partner relationships and HIV risk behaviors among women offenders

The HIV infection rate is increasing among women in general and for female inmates specifically (Maruschak 2004), which makes understanding the correlates of risky sexual behaviors critical for this population. Partner relationships, particularly the extent to which women perceive they have power within the relationship, may be important in modeling risk behaviors. Few studies have considered the association between relationship power and HIV risk behaviors among women offenders. This study examines women's perceptions of their relationships using the Sexual Relationship Power Scale (Pulerwitz, Gortmaker, & DeJong 2000) and NIDA's HIV Risk Behavior Assessment (NIDA 1995). Data were collected from female inmates in four prisons as part of the Reducing Risky Relationships for HIV protocol being conducted through the NIDA's Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) cooperative agreement. Women reported whether they had engaged in five types of unprotected sex in the month prior to incarceration. Logistic regression models of the associations between relationship power and five types of unprotected sex revealed some support for the importance of power as a protective factor in reducing the odds of unprotected sexual behaviors. Implications and findings are presented to add to understanding of partner relationships and HIV risk behaviors.

Variations in sexual risks in drug users: emerging themes in a behavioral context

Drug users are an especially complex population among those studied in HIV risk behavior research. Although injection drug use accounts for over one third of the cumulative HIV transmission in the United States, the scope of the direct and indirect impacts of all drug use is difficult to quantify, especially in relation to attributing HIV to drug use directly, via parenteral exposures, or indirectly, through unsafe sex. Important behavioral issues such as social and drug network overlaps, partner selection, and the combinations of illicit drugs with erectile dysfunction medications have added complexity to the study of sexual behavior in drug users. This review covers recent substantive research in the United States and Canada on current themes in sexual risk behavior in injection drug and non-injection drug users. We address gender, situational, and sexual preference factors that may influence sexual behaviors affecting HIV risk by class of drug and route of administration. Special attention is paid to minority populations, both sexual and racial/ethnic, as their marginalized role in contemporary society places special barriers to risk reduction.

The social epidemiology of HIV transmission among African American women who use drugs and their social network members

Despite 15 years of prevention efforts, recent increases in HIV infection have been documented for Black women in the US. Little is known about the role played by HIV status disclosure in high HIV prevalence communities. 180 Black women who used drugs in the past 30 days were recruited between May 2002 and May 2004 in New York City. Women were administered a structured network questionnaire and HIV serotested. Risk practices, HIV status disclosure within networks and mixing patterns by known HIV status are examined. Most (85%) women had used crack in the past 30 days; 48 (27%) had injected drugs, 65 (36%) reported anal sex, and 99 (55%) reported sex work at some time. Forty (22%) women were HIV-seropositive; 29 (16%) knew their seropositive status. Of high risk individual behaviours, only a history of sex work was associated with an HIV-seropositive status [(aOR=3.0; 95%CI: 1.3-7.3), p=.01]. Few (7%) of 600 network members disclosed an HIV positive status, although 73% were sex or drug use partners. Women who knew themselves to be HIV-infected were more likely than other women to report HIV-infected network members [(OR=1.5; 95%CI: 1.1-6.4), p=.03]. However, only 51% of network members disclosed an HIV status and women disclosed to 50% of their network members. In a context of high background HIV prevalence and low levels of HIV status disclosure, serodiscordant mixing patterns likely facilitate transmission.

Understanding the HIV risk reduction needs of heterosexual African American substance-abusing men

With the increasing prevalence of HIV/AIDS, nurses find themselves caring for diverse populations at risk for HIV. One subpopulation at risk is African American men with a history of substance use. To better understand the risk reduction needs of these men, a focus group was conducted with 16 African American men attending an outpatient drug treatment program in Philadelphia. The purpose was to identify perceptions of HIV risk, engagement in HIV risk behaviors, and barriers to condom use in order to generate recommendations for risk reduction programs tailored to the needs of this population. Results revealed that African American substance-abusing men perceive themselves to be at risk for HIV infection and other adverse health outcomes yet lacked adequate information related to HIV prevention. The need for culture- and gender-specific interventions to reduce HIV-related risk behaviors among African American substance-using men is discussed.

The role of sexual transmission of HIV infection among injection and non-injection drug users

Many early studies of injecting drug users (IDUs) suggested that most HIV infections in this population were due to needle sharing and that sexual transmission was negligible or was overshadowed by parenteral routes. A few of the early studies suggested a potentially important role for heterosexual transmission, but these tended to be limited to cross-sectional data or had only a few years of prospective follow-up. Studies of sexual risk factors for HIV infection among non-injecting drug users (NIDUs) are similarly sparse. Recently, investigators prospectively examined both drug-related and sexual risk factors for HIV seroconversion among male and female IDUs with an adequate number of person-years to identify statistically significant associations. Other studies among never and former IDUs have identified associations suggesting that sexual transmission accounts for a substantial number of HIV seroconversions in these populations. Herein, highlights are discussed from recent investigations among IDUs in Baltimore, Maryland, and corroborating findings from the literature. Results from a 10-year prospective analysis of the ALIVE study and an analysis of the REACH studies spanning a 7-year period indicate that sexual risk factors for HIV infection are important in both female and male IDUs. These findings underscore the need for HIV interventions among drug users that incorporate sexual risk reduction. Based on the existing literature, a narrow focus on injection-related risks is an ineffective prevention strategy. Interventions that target specific subgroups of high-risk IDUs, such as men who have sex with men and inject drugs (MSM-IDUs), sex worker-IDUs and HIV-infected IDUs, deserve special attention.

Sexual risk reduction among HIV-positive drug-using men who have sex with men

According to the US Centers for Disease Control, the majority of new HIV infections are the direct result of unprotected sexual relations between serodiscordant individuals. Thus, the development of behavioral interventions to increase the safer sex practices of HIV-positive individuals has the potential to reduce the number of new infections. Currently, less than 1% of the total US population is infected with HIV. Targeting behavioral interventions to this smaller group of HIV-positive individuals has the potential for making cost-effective reductions in the number of new infections. Despite reports that some HIV-positive individuals continue to engage in high-risk behaviors, interventions designed to prevent secondary transmission of HIV are rare. In this era of highly active antiretroviral therapy (HAART), interventions for HIV-positive individuals are more critical than ever to address the unique challenges and issues they face regarding disclosure and partner notification, use of HAART and sexual risk behavior, and HIV-related stigma. Although a growing number of reports document the efficacy of sexual risk reduction interventions for HIV-positive individuals, to date none of these studies have focused on drug-using populations. This article focuses on sexual risk reduction interventions for HIV-positive men who have sex with men (MSM), the largest group of HIV-positive individuals in the United States. It reviews factors associated with high-risk behaviors and discusses some findings from research with HIV-positive methamphetamine users, including (1) data from a small qualitative study and its implications for the development of new interventions, and (2) baseline data from an ongoing large-scale study of the efficacy of a theory-based sexual risk reduction intervention for HIV-positive methamphetamine-using MSM. The article concludes with a discussion of future research issues, including, for example: Can sexual risks be reduced in the context of active drug use? Are different patterns of drug use, or specific drugs, associated with increased risk behavior? How do gender, race, and culture relate to the efficacy of specific interventions?

Prevalence and Risk Factors for HIV Among Sniffers, Short-Term Injectors, and Long-Term Injectors of Heroin

The prevalence of HIV and associated risk behaviors were assessed among three groups of heroin users: long term injection drug users (LTIDUs), new injection drug users (NIDUs), and heroin sniffers (HSs) with no history of injection. HIV seroprevalence was similar among NIDUs (13.3%) and HSs (12.7%). LTIDUs had almost twice as high a level of HIV infection (24.7%). After including drug use and sex behavior variables in logistic regression models, both drug and sexual risk factors remained in the models. Attributable risk percent (APR) from injection for HIV infection among injection drug users was estimated to be 55.7% for LTIDUs and 5.8% for NIDUs. High-risk sex behavior plays an important role in the prevalence of HIV among drug users and accounts for nearly all the infection among NIDUs. Both injection and sexual risk behaviors need to be stressed in HIV prevention and intervention programs aimed at drug users.

The dynamics of substance use and sex networks in HIV transmission

This article (1) reviews the research to identify mechanisms that may underlie HIV heterosexual transmission in developed and developing countries, (2) examines linkages between sex and substance use HIV transmission risks, and (3) describes sex network measurement issues relevant to developing HIV preventive interventions. The research contributions of developed countries to understanding sexually transmitted HIV have long recognized the influence of substance use and sex networks. Research in developing countries has contributed significantly to the environmental and biological understanding of HIV sexual transmission dynamics. Although much of the research in developing countries has recruited participants from venues where alcohol or other substance use is pervasive (e.g., truck stops), few studies have explicitly examined the relationship between HIV sex risk and substance use in these contexts. Finally, sex network characteristics and structural features, which have been found to play identifiable roles in the spread of HIV, are measurable at the individual level and can contribute substantively to the development and the evaluation of HIV-preventive interventions implemented at the network or community level.

Assessing the Consequences of Using Self-report Data to Determine the Correlates of HIV Status: Conditional and Marginal Approaches

This article examines whether relationships between individual characteristics and HIV status can be identified when self-report data are used as a proxy for HIV serotest results. The analyses use data obtained from HIV serotests and face-to-face interviews with 7,256 out-of-treatment drug users in ten sites from 1992 to 1998. Relationships between 17 individual characteristics and HIV status (measured both by self-report and serotest results) were determined by (a) comparing and evaluating the fit of both standard and "nonstandard" loglinear models, and (b) evaluating the fit of marginal homogeneity models. The loglinear analyses showed that HIV serostatus was related to individual characteristics in 38 percent of the relationships. In most cases, the strength of the relationships between HIV status and individual characteristics did not differ when HIV status was measured with self-report data.

Contextual factors and other correlates of sexual risk of HIV among African-American crack-abusing women

This study examined differences in contextual factors, substance use, sexual risk behaviors, and comorbid histories between African-American, out-of-treatment, crack-abusing women who had either a single sexual partner or multiple partners. Bivariate analysis indicated that women with multiple partners were more likely than women with a single partner to be homeless, financially dependent, and to have histories of sexual, physical, and emotional abuse. Women with multiple partners reported higher levels of depression, anxiety, and more symptoms of posttraumatic stress disorder (PTSD). In multiple logistic regression analysis, being unemployed, difficult childhood, and number of days of crack use in the previous 30 days, longer crack runs, and more frequent unprotected fellatio were associated with increased odds of having multiple sexual partners. Being married or living as married was associated with decreased odds of having multiple sexual partners. The importance of assessing contextual and historical factors and implications for future research is discussed.

Reducing HIV sexual risk among African American women who use drugs: hearing their voices

A pilot study was conducted to understand women's realities, perspectives, and perceived needs regarding the interaction between substance use, types of sexual relationships, and the challenges and barriers they pose to practicing safer sex. An additional purpose was to examine this population's willingness to participate in the program and receptiveness to the components of proposed interventions. Data were collected in this descriptive, exploratory study by the use of one focus group. Twelve African American women between 20 and 55 years of age who had previous drug detoxification experience participated in a 3-hour focus group. All participants were sexually active as well as current users of illicit substances, and all but one had traded sex for money, drugs, or alcohol. The focus group interview was guided by a semistructured questionnaire. Participants were recruited by counselors in detoxification units. Each unit counselor was asked to randomly select a third of their residents, explain and read the purpose of the focus group, and get the residents' verbal consent to participate. The women discussed their sexual behaviors and drug use that increased their risk for acquiring HIV. They provided insight about the effects of different drugs on one's sexual behavior, motivation for sex, and reasons for unsafe sex and made recommendations for HIV prevention intervention. Participants agreed that safer sex and healthy living intervention would be most beneficial if placed within the context of a detoxification program. The juxtaposition of increased sexual risk behavior and the potential to acquire and transmit HIV infection suggests the urgency of intervening with African American women who are substance abusers.

Case-crossover study of partner and situational factors for unprotected sex

OBJECTIVES

To identify situational and partner characteristics associated with unprotected sex among women at risk for HIV infection.

METHODS

The most recent unprotected and protected sexual encounters were compared using a case-crossover design among 1,647 women enrolled in a prospective cohort study conducted in six U.S. cities. Information collected via audio computer-assisted self-interview included detailed situational and partner characteristics for participants' most recent sexual encounters, with and without condom use. Paired odds ratios (ORs) and 95% confidence intervals were calculated for situational or partner characteristics that may differ between unprotected and protected sexual encounters, using conditional logistic regression.

RESULTS

In the adjusted analysis, partner age of older than 40 years (OR = 2.42), partner type (OR = 2.45 for a "steady" partner), partner use of alcohol (OR = 1.67) and drugs within 2 hours (OR = 1.42) of the sexual encounter, time since the encounters (OR = 0.41, 0.33, and 0.19), and exchange of sex for money or drugs (OR = 0.68) remained significantly associated with women's most recent unprotected sexual encounter.

CONCLUSIONS

Considerations related to partner and relationship characteristics should provide information for the development of interventions for women.

Early life sexual abuse as a risk factor for crack cocaine use in a sample of community-recruited women at high risk for illicit drug use

Subjects for this study were 1,478 community-recruited women sexual partners of male injection drug users who were participants in the National Institute on Drug Abuse (NIDA)-supported Women Helping to Empower and Enhance Lives (WHEEL) project. This study assessed the association between child/adolescent sexual abuse--including specific type of abuse and perpetrator of abuse--and lifetime crack use in this sample of women. About 64% of sample women had ever used crack; 56% had been sexually abused by age 18. In logistic regression analyses, any sexual abuse in childhood, penetrative sexual abuse in childhood, and sexual abuse by a family member in childhood were significantly associated with lifetime crack use. Sexual abuse in adolescence was indirectly associated with lifetime crack use through running away from home and rape in adulthood. Given that many of these subjects reported drug treatment experience, such programs may provide the best setting for helping women with both substance use and sexual abuse issues.

HIV and AIDS risk behaviors among female jail detainees: implications for public health policy

OBJECTIVES

We examined the sexual and injection drug use HIV and AIDS risk behaviors of female jail detainees.

METHODS

The sample (n = 948) was stratified by charge type (felony vs misdemeanor) and race/ethnicity (African American, non-Hispanic White, Hispanic, other).

RESULTS

Non-Hispanic White women, women arrested for less serious charges, women who had prior arrests, women arrested on drug charges, and women with severe mental disorders were at especially high risk for sexual and injection drug transmission of HIV and AIDS.

CONCLUSIONS

Many women at risk for HIV and AIDS--women who use drugs, women who trade sex for money or drugs, homeless women, and women with mental disorders--eventually will cycle through jail. Because most jail detainees return to their communities within days, providing HIV and AIDS education in jail must become a public health priority.

Gender, violence and HIV: women's survival in the streets

In this article I propose that gender inequality promotes--directly or indirectly--vulnerability to HIV as a consequence of a multidimensional violence (structural, symbolic and physical) experienced by injection drug using (IDU) women in The Mission District (San Francisco). Given the female subordinated position stipulated by the street ideology, I analyze how drug dependence afforded by precarious strategies of subsistence places IDU women under multiple dangers and threats. In this setting, unequal gender relations are part of a complex system of transactions in the street economy and a way to reduce or increase the everyday violence. Facing multiple dangers and risks, some women adopt a subordinated position, some try to negotiate the conditions of the exchanges and the others resist the exploitation. Finally, everyday violence under conditions of gender inequality and scarcity of resources imposes a logic defined by the challenge of survival under the threat of immediate dangers, which transform HIV into a secondary risk.

Concurrence of drug users' self-report of current HIV status and serotest results

This study examines the concurrence of drug users' self-reports of current HIV status with serotest results. The analyses are based on data obtained from face-to-face interviews with 7,256 out-of-treatment injection drug and/or crack users in 10 sites that participated in the Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research Program (funded by the U.S. National Institute on Drug Abuse ). Although the degree of concurrence between HIV-negative individuals' self-reports of their current HIV status and their serotest results was high (specificity, 99%), this was not the situation for individuals who tested positive for HIV (sensitivity, 44%).

HIV prevention in single, urban women: condom-use readiness

OBJECTIVE

To understand women's readiness to use condoms and their perceived pros and cons for condom use.

DESIGN

Comparative, descriptive design guided by the Transtheoretical Model.

SETTING

Data were collected at two urban primary health care centers in western New York.

PARTICIPANTS

364 single urban women with steady (main) or other (casual, concurrent, multiple, new) sexual partners. Most participants were young (mean age of 27 years), economically disadvantaged women of color.

MAIN OUTCOME MEASURES

Each participant completed an anonymous questionnaire that included items for the stage of change algorithm, decisional balance of the pros and cons of condom use, sexual history, and HIV risk information.

RESULTS

Most women were in the early stages of change (not intending to use condoms), but those with other partners were further along in the stages of change for condom use than those with steady partners. The pros or advantages of condom use differed for these women depending on partner type. The change in the balance between the pros and cons occurred as theoretically predicted for women with steady and other partners.

CONCLUSION

Effectiveness of HIV prevention interventions for women may be enhanced if they are tailored to both readiness to change and partner type.

Assessing the relationship between child sexual abuse and marginal living conditions on HIV/AIDS-related risk behavior among women prisoners

OBJECTIVE

There were two aims in this research. First, to examine the relationships between childhood sexual abuse and HIV drug and sexual risk taking behaviors among female prisoners, and second, to examine the relationship between a marginal adult living context and HIV drug and sexual risk taking behavior among female prisoners.

METHOD

The data were collected through face-to-face interviews with a random sample of 500 women at admission to prison in 1994. Differences between women who were sexually abused while growing up (n = 130) were compared to women who reported no sexual abuse (n = 370) along various demographic, and HIV drug and sexual risk taking dimensions.

RESULTS

A history of sexual abuse while growing up was associated with increased sexual risk taking behaviors in adulthood. A marginal adult living situation also emerged as an important factor increasing the risk for HIV infection. Examining the co-occurrence of both childhood sexual abuse and adult marginal living context revealed a strong relationship between these two factors and HIV risk taking activities.

CONCLUSIONS

The findings indicate that childhood sexual abuse may be a predictor for HIV sexual risk taking behaviors among incarcerated women. The marginal and chaotic adult living style of these women was also associated the extent of their HIV drug and sexual risk taking behaviors. Our research suggests that the co-occurrence of sexual victimization and marginality is a stronger predictor of HIV risk than each variable alone.

Sexual and drug use behaviors among female crack users: a multi-site sample

The purpose of this paper was to compare female crack users who report exchanging sex for drugs and/or money with female crack users who did not report exchanging sex for drugs and/or money. A multi-site sample of (n = 4667) female crack users who participated in the National Institute of Drug Abuse (NIDA) AIDS Cooperative Agreement Project from 20 sites were interviewed. Statistical analysis compared two groups on selected variables of interest: women crack users who reported exchanging sex for drugs and/or money (n = 2658) and women crack users who did not report exchanging sex (n = 2009). Results indicated that both groups of women had frequent unprotected sex. However, women who exchanged sex had more sexual partners, had sex more often, used drugs before and during sex more often, and had a higher rate of STDs than women who did not exchange sex. In addition, African-American women, homeless women, and women who reported past substance abuse treatment were about twice as likely to exchange sex. Regional differences were also examined.

Acceptability of formulations and application methods for vaginal microbicides among drug-involved women: results of product trials in three cities

BACKGROUND AND OBJECTIVES

Female-controlled methods of HIV prevention, such as vaginal microbicides, are urgently needed, particularly among drug-involved women. Acceptability research is critical to product development.

GOAL

To assess the acceptability of forms and application methods for future microbicides.

DESIGN

Eighty-four drug-involved women were introduced in groups to three lubricant products, asked to try each for 3 weeks, and scheduled for individual follow-up interviews.

RESULTS

Participants and their partners felt positive about the products, and expressed willingness to use microbicides if they were shown to be effective against HIV. Women agreed on product characteristics that influenced their reactions (e.g. ease of insertion, degree of "messiness"), but often disagreed on whether their reactions to these characteristics were positive or negative.

CONCLUSION

Development of acceptable and effective HIV-prevention products depends on understanding the interaction between characteristics of the products and the characteristics and perceptions of women. Levels of sexual risk and acceptability factors based on drug-use patterns, race and ethnicity, culture, age, and types and attitudes of male partners suggest that a "one size fits all" approach will not win broad acceptance among drug-involved women.

Measuring perceived barriers to condom use: psychometric evaluation of the Condom Barriers Scale

A programmatic series of three studies developed and evaluated the Condom Barriers Scale (CBS), an instrument measuring women s perceived barriers to condom use for prevention of HIV and other sexually transmitted diseases. Following item generation and selection, Study 1 evaluated the CBS in a sample of minority women (N = 178), reduced the number of items, assessed the factor structure, evaluated the internal consistency, and explored the convergent validity of the CBS. In Study 2, the CBS was administered to a cross-validation sample (N = 278). Confirmatory factor analysis and internal consistency were compared against the original sample and construct, criterion, and discriminant validity were assessed. In Study 3 (N = 30), temporal stability of the CBS was evaluated. The resulting instrument appears to have sound psychometric properties and can be used to measure a key construct in the leading theoretical models of health behavior for which a measure with known psychometric properties previously has not been available.

Experiences of violence in HIV-seropositive women in the south-eastern United States of America

Women represent one of the fastest growing groups being diagnosed with HIV infection. Because of the circumstances under which they live, women at the highest risk for HIV infection may also be at risk for verbal, physical and sexual violence. The purpose of this study was to examine the frequency and type of violence experienced by women infected with HIV, and describe associations between reported violence, self-esteem and sense of competence. The study used a descriptive design and was conducted in the south-eastern United States. The sample consisted of 194 women infected with HIV. Women were primarily single, African-Americans residing in urban areas with an annual household income of less than $10,000 per year. Participants completed face-to-face interviews using a structured questionnaire which included a frequency of violence scale, Rosenberg's self-esteem scale, and Pearlin and Schooler's mastery scale. Approximately 15% of women reported at least one event of physical abuse and 55% at least one event of verbal abuse in the past 6 months. Verbal abuse experienced by women was the strongest net negative predictor of self-esteem and competence. These findings indicate that HIV-infected women are at risk for experiencing physical abuse and verbal abuse, and the experience of violence is associated with lower self-esteem and competence.

Geographic proximity, policy and utilization of syringe exchange programmes

The objective of the research was to assess the effects of geographic proximity on the utilization of syringe exchange among injection drug users (IDUs) in New York City. Between 1994 and 1996, 805 IDUs were interviewed with a structured questionnaire. Geographic proximity was defined as living within a ten-minute walk. Eighty-one per cent of IDUs who lived close typically used a syringe exchange compared to 59% of those who lived further away. In multiple logistic regression analysis, those who lived close remained (adjusted odds ratio of 2.89; 95% CI 2.06 to 4.06, p = 0.001) more likely to use syringe exchange. Those who lived close were less likely to have engaged in receptive syringe sharing at last injection (adjusted odds ratio = 0.45, 95% CI 0.24 to 0.86, p = 0.015). In conclusion, locating exchange services in areas convenient to large numbers of IDUs may be critical for prevention of HIV infection.

Distribution along a stages-of-behavioral-change continuum for condom and contraceptive use among women accessed in different settings. Prevention of HIV in Women and Infants Demonstration Projects

The numbers of women of childbearing age in the US with HIV and AIDS from heterosexual transmission continues to rise. Behavioral interventions remain the best means of preventing transmission of HIV. Program planners often implement interventions to promote behavioral change in a wide range of settings such as family planning or sexually transmitted disease clinics, drug treatment facilities, or medical facilities that serve high risk and HIV positive women. Women recruited in different types of settings, however, may differ with respect to their experience with, attitudes toward, and willingness to use condoms and contraception. Such differences should be considered when tailoring interventions to the populations being served. We examined the readiness to use condoms and contraception among 3784 women in four cities recruited in three different types of settings: community, facilities not targeted to HIV positive women and medical facilities for HIV positive populations. Readiness to use condoms or contraception was measured using The Transtheoretical Model of Change. Women reported being in different stages along the continuum of condom and contraceptive use in the three settings. A greater proportion of women in the HIV-facility, 45%, had used condoms consistently for the previous 6 months compared to women in the other two settings (12% and 11%). Similarly, variation across settings was seen for contemplation of consistent contraceptive use to prevent unintended pregnancies. The variability in the distribution of condom and contraceptive use across settings underscores the importance of assessing the readiness for the behavior change and designing interventions that meet the specific needs of the populations being served.

Women inmates' risky sex and drug behaviors: are they related?

The large concentration of female illicit drug users in state correctional facilities prompted an examination of the associations among different types of drug use and sexual risk factors related to human immunodeficiency virus (HIV) among women inmates. A consecutive sample of 805 women felons admitted to the North Carolina Correctional Institution for Women between July 1991 and November 1992 was interviewed. Of these inmates, 651 had complete information on relevant characteristics. Of the women inmates, 73% had used drugs prior to incarceration; most women were crack smokers only (33%), followed by non-drug users (27%), other drug users (19%), crack-smoking injecting drug users (15%), and injecting drug users only (6%). Inconsistent condom use with multiple sex partners, a history of a diagnosed sexually transmitted disease (STD), a drug-injecting sex partner, or exchanging sex for money or drugs prior to incarceration were reported by 55% of the women. Sexual risk factors differed across different types of drug users, with crack-smoking injectors being placed at greatest potential risk for exposure to heterosexually transmitted HIV, followed by injecting drug users, crack smokers, and then other drug users. Given the differential associations between sexual risk factors and types of drug use, prison-based sexual-risk reduction strategies should be tailored to specific types of drug users. In times of limited resources, special attention should be given to crack smokers and/or drug injectors.

Assessment of HIV risk

Based on the review of existing instruments and analysis of problems encountered in clinical and research practice with one of the most commonly used assessment instruments, the RAB, this paper proposes a number of solutions aimed at improving validity, and efficiency of assessment of HIV risk in drug abusing populations. Briefly, five domains of assessment are discussed: intravenous drug use, high-risk sexual behaviors, knowledge of HIV transmission and methods of prevention, psychological aspects of behavioral change, and epidemiological factors of HIV transmission. The paper discusses also changes in format, scope, and context, as well as scoring procedures that may improve discriminability and sensitivity to detect change of a comprehensive HIV risk assessment instrument. Finally, a process of developing an HIV risk assessment instrument, the ARI-I, which is based on the proposed recommendations and which incorporates methodological improvements discussed in the paper is briefly described.

Rectal microbicides for U.S. gay men. Are clinical trials needed? Are they feasible? HIVNET Vaccine Preparedness Study Protocol Team

BACKGROUND AND OBJECTIVES

Incomplete condom use during anal sex persists among gay men; microbicides may provide additional protection. Despite the absence of efficacy or safety data, many gay men use sexual lubricants containing nonoxynol-9 (N-9), a detergent-based spermicide under evaluation for efficacy as a vaginal microbicide.

GOAL

Evaluate unprotected sex, lubricant use, and attitudes regarding possible participation in clinical trials of rectal microbicides among high-risk human immunodeficiency virus-(HIV) seronegative U.S. gay men in six cities.

STUDY DESIGN

A total of 3,257 gay men were interviewed and responded to a self-administered questionnaire at enrollment into a longitudinal cohort study of HIV seroincidence.

RESULTS

Among 2,216 men who practiced receptive anal intercourse in the previous 6 months, 438 (20%) reported they never used condoms. More than three fourths of 3,093 men who had anal sex used lubricants more than 80% of the time. 41% of whom actively sought N-9 containing products. About two thirds said they were definitely or probably willing to participate in rectal microbicide clinical trials.

CONCLUSION

Condom use is imperfect among men who report anal sex. N-9 lubricants are popular. Most gay men in this cohort indicate willingness to participate in rectal microbicide studies.

HIV sex and drug risk behavior and behavior change in a national sample of injection drug and crack cocaine using women

This paper describes HIV sex and drug risk behavior and behavior change of injection drug and crack cocaine using women enrolled in a national multi-site Cooperative Agreement program. Baseline data on the 1,403 women who were randomly assigned to a two session intervention that was standardized across sites indicate that sex and drug risk behavior for becoming infected with HIV was considerable. Six-month post intervention follow-up data for the same sample of women show that significant reductions in sex and drug risk behavior were observed for the entire sample of women for the risk variables under study. Significant reductions were also demonstrated for various sub-groups of women enrolled in the study on most of the sex and drug risk variables. Given these findings, it appears that the standard intervention was effective in assisting drug using women reduce their behaviors that put them at risk of becoming infected with HIV. Further research in needed on the development and evaluation of HIV interventions that target specific risk behaviors and various HIV risk behavior profiles of women.

Urban crack users: gender differences in drug use, HIV risk and health status

This study assessed gender differences in drug use, HIV risk, and health status in a sample of urban crack users. Using targeted sampling, 1434 crack users (66% male and primarily African-American and Puerto Rican), were recruited from the streets of East Harlem, New York City. A standardized, structured interview was administered, drug use was validated by urinalysis, and HIV testing was offered. Gender differences were observed on sociodemographic variables and patterns of drug use. Other than welfare, men and women cited different major sources of income. Women reported greater use of crack, and men were more likely to use injection drugs as well as crack. Data on sexual risk indicated that women had more sexual partners than men, but the percentage of unprotected vaginal sex for both men and women was greater for those who did not exchange sex for drugs and/or money. The number of persons already infected with HIV was substantial. Many reported histories of other sexually transmitted diseases which were generally higher among men. Future research should investigate the relationship between gender and other factors (e.g., ethnicity, geographic location) associated with HIV risk.

Social influences: living arrangements of drug using women at risk for HIV infection

The purpose of this study was to explore the associations among living arrangements, HIV seroprevalence, and HIV risk and protective factors among 1,322 drug users participating in the University of Miami CARES (Community AIDS Research and Evaluation Studies) HIV intervention program. Living arrangements may be associated with HIV prevention behaviors; however, these influences can be either protective or destructive and therefore merit further examination. Statistical analyses indicated differences in the living arrangements of women compared with men, and significant associations were noted among women's living arrangements, HIV seroprevalence, risk behaviors and protective behaviors. The data from this study suggest that future HIV prevention research should investigate not only high-risk individuals, but persons with whom they interact often, especially those with whom they live or with whom they have sex. The next phase of HIV and drug interventions should be attentive to the incorporation of social context and social influences, paying particular attention to understudied populations such as high-risk women.

Predictors of HIV infection among women drug users in New York and Miami

In the US, the number of women diagnosed with AIDS continues to increase. In this study, women in New York City (East Harlem) and Miami, two sites with high rates of drug use and HIV infection, were first compared on sociodemographic variables and risk behaviors. Logistic regression analyses were used to identify significant, independent predictors of HIV infection in each city. In comparing women from the two cities, several differences in sociodemographic characteristics and drug use were observed. In both cities, ever exchanging sex for drugs and/or money was predictive of HIV infection; and in East Harlem only, other lifetime risk variables independently predicted HIV infection: drug injection, having a sexually transmitted disease, and not having graduated from high school. Results suggest that intervention efforts with women who exchange sex should be intensified in both cities. Also, further comparisons of women drug users in AIDS epicenter cities are necessary to provide information on similarities and differences in sociodemographic characteristics and individual risk behaviors. More research attention should be focused on examining the social context of HIV risk in order to develop innovative intervention strategies which focus on the link between contextual factors and HIV infection.

Cluster analysis of HIV intervention outcomes among substance-abusing women

The study described here presents an innovative approach to analyzing intervention outcomes among women substance abusers participating in a national HIV prevention research study funded by the National Institute on Drug Abuse. We used cluster analysis to divide the women in our sample (N=557) into four distinct subgroups predominantly characterized by differences in drug use, injecting risk, sexual behaviors, and drug and sexual risk combined. The four subgroups resulting from this process were primary crack-using women, primary needle-using women, high-frequency needle-using women, and women with multiple drug and sex risk behaviors. Our analysis focuses on changes in self-reported risk behaviors from baseline to 6-month follow-up. In general, the results clearly indicate that the women are heterogeneous; that is, the subgroups exhibit varying patterns of drug use, injecting risk, sexual behavior, and HIV seropositivity. Significant outcomes were found in many areas, indicating positive changes in risk behaviors. The two smaller subgroups of women--high-frequency needle users and those in the multiple-risk behavior subgroup--reported the highest rate of high-risk behaviors and seropositivity but also showed the greatest change at follow-up. A particularly important finding resulting from our analytical approach is that well over half the women in our sample were primary crack users (n=313). This finding is even more significant in light of the fact that the Cooperative Agreement specifically tried to include 70% or more participants who were injectors. Although the rate of HIV seropositivity is not as high for this crack-using subgroup as for the two smaller needle-using subgroups, a greater number of "women who are HIV positive" are in this primary crack-using subgroup than in all the other subgroups. Most of the crack-using women reported that they were not currently injecting drugs and never shared needles, but 10% were seropositive for HIV, suggesting that their risk comes primarily from sexual behaviors. Behaviors in this larger subgroup of women did not change as dramatically as those of women in the smaller subgroups; however, the women did show improvement in areas related to indirect risk (e.g., alcohol and crack use) and in several areas where change is most needed (e.g., trading sex for drugs and using condoms). The results demonstrate a promising alternative approach to analyzing substance abuse and HIV risk behaviors, and they suggest the need for further research on alternative interventions for women with different patterns of risk behaviors.

Sociometric risk networks and risk for HIV infection

OBJECTIVES

This study examined whether networks of drug-injecting and sexual relationships among drug injectors are associated with individual human immunodeficiency virus (HIV) serostatus and with behavioral likelihood of future infection.

METHODS

A cross-sectional survey of 767 drug injectors in New York City was performed with chain-referral and linking procedures to measure large-scale (sociometric) risk networks. Graph-theoretic algebraic techniques were used to detect 92 connected components (drug injectors linked to each other directly or through others) and a 105-member 2-core within a large connected component of 230 members.

RESULTS

Drug injectors in the 2-core of the large component were more likely than others to be infected with HIV. Seronegative 2-core members engaged in a wide range of high-risk behaviors, including engaging in risk behaviors with infected drug injectors.

CONCLUSIONS

Sociometric risk networks seem to be pathways along which HIV travels in drug-injecting peer groups. The cores of large components can be centers of high-risk behaviors and can become pockets of HIV infection. Preventing HIV from reaching the cores of large components may be crucial in preventing widespread HIV epidemics.

High Risk Pregnancies: Teenagers, Poverty, and Drug Abuse

The real problem is not teenage pregnancy alone, but the destructive combination of single motherhood, poverty, and drug abuse. The consequences of being a poor, inner-city, single mother with an expensive drug habit may include prostitution, drug dealing, dependency upon welfare and/or extra support from an already overwhelmed family system, and neglected children. Almost inevitably, the children exhibit cognitive deficits and behavioral problems, may turn to drugs at a young age, and may have an early involvement with the criminal justice system. To design effective prevention programs it is essential to understand the myriad complex risk factors that affect the lives of these vulnerable young women. As the first stage in a larger study of motivation and readiness for change and the development of self-protective health practices, interview data were collected from 30 participants. Sixteen were residents and staff who had graduated from a drug treatment program and 14 were undergraduate and graduate students, all of whom had been pregnant as teenagers. The results yielded a surprising commonality of experiences for both groups that included childhood physical and sexual abuse, coercive adolescent sexual relationships, early first sexual contact, early first pregnancies (often as a function of rape or incest), abortions, and chemical dependency, especially during pregnancy.