National Institute on Drug Abuse RESEARCH MONOGRAPH SERIES The Context of HIV Risk Among Drug Users and Their Sexual Partners 143 U.S. Department of Health and Human Services • Public Health Service • National Institutes of Health The Context of HIV Risk Among Drug Users and Their Sexual Partners Editors: Robert J. Battjes, D.S.W. Zili Sloboda, Sc.D. William C. Grace, Ph.D. NIDA Research Monograph 143 1994 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service National Institutes of Health National Institute on Drug Abuse 5600 Fishers Lane Rockville, MD 20857 ACKNOWLEDGMENT This monograph is based on the papers from a technical review on “The Context of HIV Risk Among Drug Users and Their Sexual Partners” held on April 22-23, 1993. The review meeting was sponsored by the National Institute on Drug Abuse. 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Trade, proprietary, or company names appearing in this publication are used only because they are considered essential in the context of the studies reported herein. National Institute on Drug Abuse NIH Publication No. 94-3750 Printed 1994 NIDA Research Monographs are indexed in the Index Medicus. They are selectively included in the coverage of American Statistics Index, BioSciences Information Service, Chemical Abstracts, Current Contents, Psychological Abstracts, and Psychopharmacology Abstracts. Contents Page A Contextual Perspective on HIV Risk Robert J. Battjes, Zili Sloboda, and William C. Grace . . . . . . . . . 1 I. Panel I - Heterosexual Males HIV Risk Behaviors of Heterosexual Male Drug Users . . . . . . . . 5 Richard H. Needle Injection and Sexual Risk Behaviors of Male Heterosexual Injecting Drug Users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Richard C. Stephens and Sonia A. Alemagno HIV/AIDS Risks Among Male, Heterosexual Noninjecting Drug Users Who Exchange Crack for Sex . . . . . . . . . . . . . . . . . 26 James A. Inciardi II. Panel II - Women Context of HIV Risk Behavior Among Female Injecting Drug Users and Female Sexual Partners of Injecting Drug Users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Diana Hartel Female Drug Abusers and the Context of Their HIV Transmission Risk Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Karen Allen Factors Associated with Sexual Risk of AIDS in Women . . . . . . 64 Ann O’Leary Ill. Panel Ill - Men Who Have Sex With Men Drug Use and HIV Risk Among Gay and Bisexual Men: An Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Robert J. Battjes Substance Use and HIV-Transmitting Behaviors Among Gay and Bisexual Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 David G. Ostrow iii Drug Use and HIV Risk Among Male Sex Workers: Results of Two Samples in San Francisco . . . . . . . . . . . . . . . . . . . . . . . . . 114 Dan Waldorf IV. Panel IV - Adolescents HIV Risk in Drug-Using Adolescents . . . . . . . . . . . . . . . . . . . . 132 Vincent L. Smeriglio HIV Risk in Adolescents: The Role of Sexual Activity and Substance Use Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Cherrie B. Boyer and Jonathan M. Ellen Going Nowhere Fast: Methamphetamine Use and HIV Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Mary Jane Rotheram-Borus, G. Cajetan Luna, Toby Marotta, and Hilarie Kelly V. Panel V - Measurement Issues The Context of Risk: Methodological Issues . . . . . . . . . . . . . . 183 Zili Sloboda Bringing the Context in From the Cold: Substantive, Technical, and Statistical Issues for AIDS Research in the Second Decade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Ann F. Brunswick The Context of Risk: Ethnographic Contributions to the Study of Drug Use and HIV . . . . . . . . . . . . . . . . . . . . . . . . . . 202 Stephen K. Koester Assessing the Reliability and Validity of Self-Reported Risk Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218 David R. Gibson and Martin Young Future Directions for Studies on the Context of HIV Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 William C. Grace, Robert J. Battjes, and Zili Sloboda iv A Contextual Perspective on HIV Risk Robert J. Battjes, Zili Sloboda, and William C. Grace For over a decade, acquired immunodeficiency syndrome (AIDS) has been identified as a major public health epidemic and a research priority of the National Institute on Drug Abuse (NIDA), the National Institutes of Health (NIH), and other components of the U.S. Public Health Service. Since the early years of the epidemic, needle and syringe sharing among injecting drug users (IDUs) has been recognized as a major vector for spread of the human immunodeficiency virus (HIV). Sexual transmission among IDUs, and from IDUs to non-IDU sexual partners, also has been a longstanding concern, as has perinatal transmission to their children. The number of IDUs diagnosed with AIDS continues to expand in the second decade of the epidemic, as does the number of related cases in IDUs’ sexual partners and their children. Approximately one-third of AIDS cases are associated with injecting drug use (Centers for Disease Control and Prevention 1993). The potential contribution of non-IDUs to HIV transmission and disease progression also has been of concern. For example, drug intoxication may lessen inhibition and facilitate engagement in sexual risk behaviors. Involvement in drug-using social networks may promote sexual contact between noninjectors and IDUs, increasing risk of HIV exposure. Some non-IDUs also engage in sex to obtain drugs or money to buy drugs. Recently, it has been recognized that crack cocaine users who engage in sex to obtain their drugs may be at especially high risk for HIV infection (Inciardi et al. 1992, 1993; Ratner 1993). Considerable progress has been made in identifying risk behaviors that contribute to HIV transmission and in enumerating the extent of injecting and sexual risk behaviors, especially for IDUs. However, much less progress has been made in clarifying the factors that may explain risk behaviors and barriers to risk reduction. To review research on drug-using and sexual behaviors of drug users that are associated with HIV transmission and to develop a research agenda for future research on risk behaviors, NIDA convened a technical review entitled The Context of HIV Risk Among Drug Users and Their Sexual 1 Partners. The review was held April 22 and 23, 1993, in Bethesda, Maryland. This monograph contains the papers presented at the technical review and recommendations emanating from it. The technical review on HIV risk behaviors evolved from an earlier meeting that NIDA convened in January 1992 as part of a planning process to develop NIDA’s 5-year plan for AIDS research. A number of areas for future research emerged from this planning meeting, with three priority areas identified for emphasis: Impact of the social context on drug injecting and drug-related sexual behaviors; Situational and temporal variations in injecting behaviors, especially considering the continuum of injection initiation, maintenance, risk reduction, and relapse; and Sexual behaviors and changes in sexual relationships in relation to developmental stages over time and in diverse interpersonal situations. These recommendations provided the foundation and framework for the technical review. The technical review considered injection-related risk behaviors of IDUs, sexual risk behaviors of IDUs and their sexual partners, and sexual risk behaviors associated with drug use in non-IDUs. The intent was to focus on the context of risk behaviors in order to clarify factors that contribute to or protect against risk and to thereby advance the knowledge base for future HIV-prevention strategies. In addressing the context of risk behaviors, authors were asked to consider situational, temporal, and developmental variation in risk behaviors, to consider differences based on level of risk (i.e., differences among individuals based on high, moderate, and low-risk behaviors), and the effects of competing risks (e.g., risks of withdrawal and overdose versus risk of HIV infection). Authors also were asked to consider psychological status, the dyad or social grouping in which behavior occurs, social networks, community context, culture, economic conditions, individual’s serostatus, and community AIDS prevalence. The monograph is organized into five sections. The first section, introduced by Needle, contains chapters on HIV risk behaviors of 2 heterosexual male drug users, with Stephens and Alemagno addressing IDUs and Inciardi addressing non-IDUs. The second section, introduced by Hartel, contains chapters on HIV risk behaviors among women. Allen addresses drug-using women, and O’Leary addresses sexual partners of IDUs. The third section, introduced by Battjes, includes chapters on homosexual and bisexual male drug users. Ostrow addresses drug use associated with sexual risk behaviors, and Waldorf addresses male prostitution and drug use. The fourth section, introduced by Smeriglio, focuses on adolescent drug users. Boyer and Ellen address HIV risk behaviors among mainstream adolescents (i.e., those who can be accessed through schools), while Rotheram-Borus and colleagues address homosexual and bisexual adolescent males who are-involved in a range of drug-using and sexual risk behaviors, including injecting drug use and male prostitution. The fifth section, introduced by Sloboda, concentrates on measurement issues in HIV risk behavior research. Brunswick sets forth a multidimensional conceptual framework to guide research in the area. Koester discusses the importance of qualitative research in gaining a better understanding of both the micro and macro contexts of these behaviors of interest. Gibson and Young examine the reliability and validity of self-reports of these risk behaviors. During the technical review, Agar, Des Jarlais, and Robles served as reactors to the formal presentations and, thereby, focused group discussion and the formulation of research recommendations. The final monograph chapter contains recommendations for future research based on the formal papers and discussion. REFERENCES Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. Vol. 5, No. 3, 1993. Inciardi, J.A.; Chitwood, D.D.; and McCoy, C.B. Special risks for the acquisition and transmission of HIV infection during sex in crack houses. J Acquir Immune Defic Syndr 5:951-952, 1992. 3 Inciardi, J.A.; Lockwood, D.; and Pottieger, A.E. Women and Crack- Cocaine. New York: Macmillan, 1993. Ratner, M.S., ed. Crack Pipe as Pimp: An Ethnographic Investigation of Sex-for-Crack Exchanges. New York: Lexington Books, 1993. AUTHORS Robert J. Battjes, D.S.W. Zili Sloboda, Sc.D. William C. Grace, Ph.D. Division of Clinical Research National Institute on Drug Abuse Parklawn Building, Room 10A- 5600 Fishers Lane Rockville, MD 20857 4 HIV Risk Behaviors of Heterosexual Male Drug Users Richard H. Needle Since reporting of acquired immunodeficiency syndrome (AIDS) cases began in the United States, over 325,000 persons have been reported as having been diagnosed with AIDS, and more than 200,000 deaths have occurred. Approximately 30 percent of AIDS cases in the United States have been injecting drug users (IDUs), and most of these AIDS classified cases (80 percent) are among heterosexual IDUs. More AIDS cases have been reported among heterosexual male IDUs (about 75 percent) than among female IDUs (Centers for Disease Control and Prevention 1993). Available surveillance data on AIDS cases do not permit tracking of trends in heterosexual male or female crack users who have become human immunodeficiency virus (HIV) infected or acquired AIDS through sexual transmission. In this monograph, Stephens and Alemagno review the injection and sexual risk behaviors of male heterosexual IDUs, and Inciardi reports on HIV/AIDS risks among male heterosexual non-IDUs who exchange crack for sex. Stephens and Alemagno focus on HIV risk-taking behaviors of IDUs related to the multiperson use of contaminated needles and other drug injection paraphernalia, their sexual risk practices, and the potential for acquiring or transmitting HIV. Their review reveals that individual behavioral patterns and risks of HIV exposure depend on a number of factors, many of which are beginning to be recognized as contextual. These factors include community prevalence, availability of syringes and paraphernalia, availability of drugs, presence of shooting galleries and needle exchanges, and availability of condoms (both female and male). They also review some newly emerging data on indirect needle-sharing practices, such as frontloading and backloading, and on the use and nonuse of condoms, sexual behaviors, and other sexual risk practices. While their review focuses on heterosexual male IDUs and emphasizes sharing of needles and other injection paraphernalia among IDUs as the major mode of HIV transmission, that practice is clearly not the only mode for acquiring or transmitting HIV infection. Stephens and Alemagno’s review of sexual practices of male heterosexual IDUs 5