Intimate relationship characteristics associated with condom use among drug users and their sex partners: a multilevel analysis
Introduction
The acquired immunodeficiency syndrome (AIDS) epidemic in the United States continues to disproportionately affect ethnic minority populations and injection drug users (IDUs, Centers for Disease Control and Prevention, 1999). In 1998, African Americans accounted for 47% persons diagnosed with AIDS, their highest proportion thus far in the epidemic. IDUs represented 24% of AIDS cases in men and 47% of those in women.
Because of the efficacy of human immunodeficiency syndrome (HIV) transmission through the sharing of used syringes, sexual risk behaviors among injectors has received less research attention than injecting behaviors in the United State (Banks et al., 1991, Rhodes et al., 1996). Studies have shown that drug users’ high rates of unprotected sexual behaviors have not decreased as extensively as injection-related risk behaviors in response to the HIV epidemic (Rhodes et al., 1996, Kwiatkowski et al., 1999). Before the HIV/AIDS epidemic, early research on drug users’ sexual behaviors focused on the effects of opiates on sexual desire (Savage, 1980, Smith et al., 1982, McWaine and Procci, 1988). Once HIV reached epidemic levels among drug users, researchers found that IDUs are sexually active and often report low levels of condom use (Banks et al., 1991, Rhodes et al., 1996). Some researchers have asserted that risky sex behaviors are increased by the direct effects of drug use such as disinhibition, euphoria, and impaired judgement (Robles et al., 1998). In a study of almost 27 000 drug users in 22 US cities, Booth et al. (2000) found that more that 80% of sexually active participants reported unprotected sex in the past month. This high percentage was not differentially associated with type of drug use, route of administration, or frequency of use. In a study of HIV-infected women, Novotna et al. (1999) found that current heroin and/or cocaine users were more likely than nondrug users to, present with a sexually transmitted disease; report a higher number of sex partners; and report less consistent condom use.
Although consistent condom use can substantially reduce the sexual transmission of HIV, long-term sex partners who do not use condoms might have difficulty in introducing condoms into their primary relationships (Banks et al., 1991, Burke et al., 1996, Skurnick et al., 1998). Condom use can conflict with the desire to commit to long-term relationships, since it may infer a level of mistrust between partners. Ethnographic research has revealed that women view nonuse of condoms as symbols of trust in their partner, faith in their partner's monogamy, and commitment to the relationship (Sobo, 1993, Sherman and Steckler, 1998). Jadack et al. (1997) found that trust in sex partners was the most frequent explanation given (20% of the sample) for not using condoms among a sample of urban, primarily African American sexually transmitted disease clinic patients. Condoms are less likely to be used in primary compared with casual relationships (McCoy and Inciardi, 1993, Paone et al., 1995, Robles et al., 1998, Kwiatkowski et al., 1999).
Most established HIV risk factors are examined solely from the perspective of the individual at risk, such as the number of sex partners an individual has or the consistency with which she or he uses condoms or shares injection equipment (McCoy and Inciardi, 1993, Booth, 1995, Burke et al., 1996, Polacsek et al., 1999). Solely focusing on the individual ignores the interpersonal context of sexual risk-taking behaviors (Rhodes and Quirk, 1998) such as social norms, roles, and relationships.
The aim of this paper is to examine the association between condom use and characteristics of relationships between drug users and their sex partners. The study's hypotheses are, (1) sex partners who live together will be less likely to use condoms consistently compared with sex partners who do not live together; (2) individuals will use condoms less consistently with sex partners with whom they are financially interdependent compared with those with whom they are not; and (3) trust will be significantly related to lower condom use for women but not for men.
Section snippets
Methods
The data used in this analysis were collected as a part of the Self-Help in Eliminating Life Threatening Diseases (SHIELD) project, a network-oriented experimental intervention. In order to gain an understanding of social aspects of risk behavior as well as the diffusion of information from the intervention, individuals, called ‘indexes’ (n=1070), were interviewed as well as members of their social networks (n=567). The study was approved by the Johns Hopkins School of Public Health Committee
Demographic characteristics of participants
Demographic information on both indexes and their sex partners were reported by the indexes. Indexes (n=703) and their sex partners (n=1003) were, 66 and 62% male; 79 and 54% unemployed; and 38 and 37-years old on average. Two percent of the indexes reported only having same sex partners. Indexes were 94% African American, 54% had at least graduated from high school, and 29% had a monthly per capita income above $1000. Fourteen percent of indexes reported being HIV-infected while only 7%
Discussion
Preceived characteristics of the drug users’ intimate relationships were significantly associated with consistent condom use. The use of GEE to adjust for clustered data provided the statistical tools needed to examine characteristics of sex partners associated with safer sex behavior. Drug users who lived with and helped their sex partners financially were significantly less likely to consistently use condoms. Being HIV-infected was significantly associated with reported consistent condom use,
Acknowledgements
This work was supported by NIDA grant #R01 DA010446 and a predoctroal training grant from the National Institute of Mental Health, grant #1F31MH11806. Special thanks to the many women and men who shared their stories and continue to work with SHIELD.
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