Regular aricleWho’s getting the message? intervention response rates among women who inject drugs and/or smoke crack cocaine
Introduction
More than 2 decades into the AIDS epidemic, reports of HIV risk reduction are encouraging. However, many individuals at risk continue to engage in risky behaviors, thereby placing themselves and others at risk for not only HIV but also other blood-borne and sexually transmitted diseases. Since the onset of the epidemic, numerous studies have explored risk factors for HIV infection among individuals who use illegal drugs. Initially, the focus was limited to injection behaviors [1]. Subsequent research has focused on sexual risk behaviors, such as unprotected sex with high-risk sex partners, having multiple partners, and having negative attitudes toward condom use [2].
Among injection and noninjection drug users, the link between drug use and sexual behaviors is often prominent. Sexual behaviors that have been associated with drug use include early sexual debut, sex without condoms, multiple sexual partners, anonymous partners, drug-impaired sex, the exchange of sex for drugs or money, and injection drug using partners [3], [4], [5], [6], [7]. Researchers have also found differences in such behaviors according to gender. For example, sex exchanging has been shown to be more prevalent among female than male drug users [8].
The HIV and AIDS epidemics have been associated not only with a route of drug administration (e.g., smoking or injection drug use), but also a particular drug or type of drug. The association between crack cocaine use, namely, crack smoking, and the sexual transmission of HIV has been well-documented [5], [7], [9], [10]. Unprotected intercourse, sex-for-crack exchanges, and a tendency to have more sexual partners have all been reported among users of crack [4], [11]. Individuals who inject drugs and those who smoke crack cocaine may encounter similar risks for infection, such as unprotected sex. However, injection drug users (IDUs) who also smoke crack may be at the greatest risk for infection [12], [13].
Recent studies have examined the nature of crack and injection drug use and risks associated with different routes of administration. In a sample of injection drug users, crack smokers, and injection drug users who smoke crack, Booth and colleagues [6] found that IDUs who also smoked crack injected drugs more frequently and were more likely to have sex with an IDU, to trade sex for drugs, to use drugs before or during sex, and to have more frequent unprotected sex than IDUs who did not smoke crack. In a more recent analysis, Booth and colleagues [12] found that those who used only crack and crack users who also injected were significantly more likely to have unprotected sex than those who only injected drugs. Irwin and colleagues [43], in a comparison of injecting and noninjecting crack smokers, reported similar findings. In particular, crack users who injected were significantly more likely to have had sex with an IDU and a greater number of sex partners than crack smokers who never injected, and they were slightly more likely to have engaged in prostitution.
Other researchers have found that crack smoking IDUs are more likely than IDUs who do not smoke crack to inject drugs, to use drugs in a shooting gallery, and to have a higher number of sexual partners [14], [15]. Among a sample of IDUs who reported smoking crack and IDUs who did not smoke, Carlson and colleagues [16] discovered differences according to route of administration as well as frequency of drug use. They found that those who used crack more frequently were less likely to also inject frequently but were more likely to use alcohol on a daily basis when compared to the IDU only group and those who used crack less frequently. In addition, IDUs who reported less frequent use (e.g., not daily) of crack were more likely to have injected with used needles and syringes [16].
Rates of HIV may also differ according to route of drug administration. In a sample of crack users from New York and Pennsylvania, Deren and colleagues [13] found HIV seropositivity to be higher among individuals who smoked crack and also injected compared to those who only smoked crack.
The importance of identifying conceptually meaningful subgroups of substance using populations has been emphasized [17], particularly among female users, who are a unique substance using group [4], [18], [19]. Even women who primarily use one drug or who report only one route of drug administration may encounter differential risks. Research among women who use crack cocaine has revealed a heterogeneous group of women whose sexual and drug using behavior, as well as potential risk for infection, are not equivalent [4], [20], [21], [22].
Although differentiation between types of drug users (e.g., IDUs who do and do not smoke crack) has been increasingly common in research examining dissimilarities in risk behavior, such differentiation has been less common in identifying trends in risk reduction over time [1], [23], [24], [25], [26], [27], [28], [29]. Assessing differences according to drug use and behavioral response rates over time can aid in public health intervention efforts, including drug treatment needs. Furthermore, few studies have compared behavior [12] and none, to our knowledge, behavioral change over time among all three types of drug users—injection only users, crack smokers, and IDUs who also smoke crack.
Previously, we reported preliminary data from an HIV risk reduction intervention among African American women who smoked crack cocaine or injected drugs [30], [31]. Results revealed that women who identified as either primary crack cocaine smokers or IDUs embraced lower risk behaviors to reduce HIV infection and transmission from baseline to 6-month follow-up. In the present investigation we sought to determine whether HIV-related sexual and drug using behavioral changes among the women differed among three types of drug users or routes of drug administration—those who only reported crack smoking, those who only injected drugs, and those who reported both injection drug use and crack smoking. In this analysis, we first examined sociodemographic and behavioral differences in these three groups. We then examined the change in HIV-related sexual and drug using risk behaviors according to route of drug administration.
Section snippets
Study procedures
Subjects were enrolled between June 1998 and January 2001 as part of an HIV risk reduction trial among HIV-negative, heterosexually active, African American women who use drugs. To be eligible, women had to be 18 years of age or older, reside in the one of the study communities, be out of drug treatment or any other institutional setting, be proficient in English, be HIV negative, have had vaginal sex with a man at least once during the month prior to the interview, and be an active illegal
Baseline differences
Sociodemographic characteristics of respondents according to route of drug administration are presented in Table 1. Ages of respondents ranged from 18 to 59 years, with the greatest proportions of IDU only participants and IDUs who also smoke crack (i.e., smoking IDUs) falling into the 40 or older age category at baseline (73 and 57%, respectively). Drug using groups differed significantly on the number of offensive acts committed in the year prior to baseline assessment, with smoking IDUs
Discussion
Of primary interest in this study were baseline risk and intervention response rates among three groups of drug users—IDUs who did not smoke crack, IDUs who did smoke crack, and crack smokers who did not inject. There were few baseline differences in drug using and sexual behaviors. Results of this analysis, and previous findings [30], [31], suggest that the intervention produced positive behavioral changes over time, but that response rates varied according to drug using group or route of drug
Acknowledgements
This research was supported by NIDA Grant R01 DA-10642 and the Emory Center for AIDS Research. The views presented in this paper are those of the authors and do not represent those of the funding agencies. We thank Hugh Klein for his assistance and all the field staff and the participants who made this study possible.
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