Sexual transmission of HIV and hepatitis involving
IDUs is an important factor in the continuing epidemics of these diseases
in the U.S. In 1997, 11 percent of the new AIDS cases reported that
year were among men and women whose sex partners were IDUs. Twelve percent
were among male IDUs who also reported having sex with other men (CDC,
1998a). High-risk sexual behavior is also strongly associated with hepatitis
B transmission (CDC, 1999).
As described in Chapter
1: Injection Drug Users Play a Key Role in the Transmission of HIV and
Other Blood-borne Infections, high-risk drug behaviors and high-risk
sexual behaviors are often linked (Chu et al., 1998). For example, a
large portion of IDUs use alcohol and/or crack cocaine, which are often
associated with increased frequencies of unsafe sexual behavior (Edlin
et al., 1994) and number of sex partners (Corby et al., 1988). Some
IDUs support their drug habits by exchanging sex for money or drugs.
Therefore, the extent to which IDUs change their sexual behaviors in
response to these diseases is critical. This is particularly true in
light of the fact that although IDUs will make large changes in their
injection risk behavior in response to concerns about AIDS, changes
in sexual behavior are generally more modest (Des Jarlais, 1995; Friedman
et al., 1993). In addition, it appears that IDUs are more likely to
reduce sexual risk behaviors with casual sexual relationships than with
their primary sexual partners (CDC/ACDP, 1999; Friedman et al., 1994;
Friedman et al., 1999) or with sexual partners who do not inject illicit
drugs (Friedman et al., 1994; Friedman et al., 1999; Vanichseni et al.,
1993). The reluctance to use condoms with main partners may be due to
concerns that doing so violates the intimacy and trust developed in
the relationship.
To date, distributing condoms and information has
commonly been used to help IDUs reduce their risk of sexual transmission.
These materials are given out for free by most outreach workers, syringe
exchange and other risk reduction programs, drug users' organizations,
and some substance abuse treatment programs. One-on-one sexual risk
reduction counseling and group interventions are also conducted by peers
to address skills building and rehearsal, interpersonal communication,
problem-solving, situational analysis, and self-management strategies.
Strategies for female drug users and sexual partners of drug users have
stressed the importance of building self-esteem, social supports, and
sexual negotiation skills to encourage safer sex practices with partners.
In developing strategies to reduce sexual transmission
among IDUs, agencies and organizations should design them with specific
target groups (for example, in-treatment versus out-of-treatment drug
users) and specific goals (for example, preventing acquisition of infection
in uninfected IDUs and preventing transmission from infected IDUs to
others) in mind. These strategies should also take into consideration
the determinants of sexual transmission, including the consistency of
condom use, the presence of concurrent STDs, the presence of concurrent
injection drug and crack use, and the extent of sexual activity while
high. Interventions designed for the sexual partners of IDUs are an
important complementary element of overall strategies for reducing sexual
transmission among IDUs.
Currently, the number of AIDS cases are increasing faster among
women than among men; heterosexual transmission is responsible
for a growing percentage of these cases (38 percent of cases among
women in 1997, as compared with 14 percent in 1987). Using a condom
is the principal way to prevent heterosexual transmission, but
its use is relatively low among the male partners of women at
risk and is partner-specific, meaning that rates of use are lower
with main partners than with other partners.
The
Prevention of HIV in Women and Infants Demonstration Projects
(WIDP) was a 5-year, multi-site intervention designed to increase
positive attitudes, behaviors, and community norms around condom
use among women at risk of HIV infection. Using the stages of
change theory, social learning theory, and the diffusion-of-innovation
theory, the WIDP built on strategies previously applied in CDC's
AIDS Community Demonstration Projects to see whether a variety
of HIV prevention activities focusing on the need to use condoms
with main and other partners would increase the use of condoms.
This 1991-1996 intervention took place in two public housing communities
in Pittsburgh, a low-income neighborhood in West Philadelphia,
and a group of inner-city neighborhoods in Portland, Oregon. Several
other communities served as a comparison group.
The
centerpiece of the intervention consisted of a series of culturally
specific role-model stories that were developed for use in each
community. In each story, the main character moved from one stage
in the stages-of-change theoretical model to the next. In each
community, 33 to 48 stories, each of which were based on interviews
with women in the community, were developed and widely distributed
as fliers, brochures, posters, and newsletters.
Several
other activities supported these stories-a peer network of volunteers
was formed to provide HIV prevention information and distribute
the stories and condoms; small businesses and neighborhood organizations
and agencies were recruited as distribution sites for the stories
and other HIV prevention information and as sites for workshops
or other activities; each intervention city also hired four full-time
outreach workers to provide individualized HIV prevention information
and condoms to women in the community.
The
WIDP reached large numbers of at-risk women with HIV prevention
messages and it was well received by community leaders, businesses,
and residents. It was also effective in encouraging women to talk
with their main partners about using condoms and to begin using
them. There was a similar, though not statistically significant,
positive change in condom use with other partners as well. One
final and notable finding was that intervention effects began
to appear only after the WIDP had been active for 2 years. In
combination with the other findings, this suggests that to be
effective in low-income, higher-risk neighborhoods, interventions
need to address the particular social, economic, and cultural
issues that affect the target population and they need to be sustained
over the long term.
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