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U.S. Department of Health and Human Services

Archival Content: 1999-2005

A Comprehensive Approach:
Preventing Blood-Borne Infections Among Injection Drug Users

Chapter 3, Section 2: Key Strategies


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.


Preventing the Sexual Transmission of HIV at the Community Level

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.

For more information: Lauby et al., 2000.

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