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U.S. Department of Health and Human Services

Archival Content: 1999-2005

HIV Prevention Among Drug Users:
A Resource Book for Community Planners & Program Managers

Impact of HIV Among Special Groups of Drug Users

As shown in the previous section, a user's drug practices and sexual behaviors, and the social context in which he or she uses drugs can all significantly influence that person's HIV risk. In addition, these practices and behaviors appear to be partly dependent on the drug users membership in one or more specific groups in which HIV risk is magnified. These groups are: women who are drug users, partners of drug users, or who trade sex; men who have sex with men and bisexual men; the mentally ill; the homeless; and incarcerated and paroled individuals.

Studies conducted on the prevalence of HIV among drug users highlight the importance of directing prevention efforts to these special groups. For example, a recent report by the Institute of Medicine cites studies showing that HIV prevalence is higher among IDUs who are minority, female, and under 30 years old than that among other population groups (Friedman et al., 1987; Normand et al., 1995; Schoenbaum et al., 1989). By taking a close look at these special groups and the circumstances that place members at high risk, program planners and managers will be able to select and design more relevant and effective HIV prevention interventions.


Data from a number of sources suggest that women should be a population of particular concern. For example, AIDS surveillance data show that an increasing proportion of AIDS cases is being diagnosed among women. HIV seroprevalence studies complement these data by showing the increasing prevalence of HIV infection in several subsets of women in particular. These include minority women and women who are at risk for HIV infection because of their own drug use or that of their partners (Normand et al., 1995). Research is only just beginning to help prevention planners understand the unique needs of these women and the circumstances that lead to their being at risk for HIV infection.

Women who inject drugs

Although the estimated ratio of male to female IDUs is 3 to 1, it is important to note that female IDUs face special risks. One study, which examined a sample of women in drug treatment, showed that these women had a faster transition from drug use initiation to abuse and dependence and greater severity of dependence as compared to their male counterparts (Anglin et al., 1987; Hser et al., 1987). Other research shows that female IDUs are more likely than their male counterparts to engage in high-risk sex with multiple partners for money or drugs, share needles, and have unprotected sex with an IDU partner (Hartel, 1994).

The substance abuse literature has shown that there are differing experiences for men and women in the drug culture (Reed, 1985; Paone, 1995). For example, compared with male IDUs, female IDUs are less likely to have social support networks, which have been shown to be protective (Reed,1985; Finkelstein,1994). Women appear to experience a heightened level of stigma associated with drug use, which, when internalized, often produces feelings of shame and guilt (Reed, 1985). Their social support system, which traditionally places a heavy focus on attachment and affiliation with others, is often damaged by drug use because such use is generally accompanied by social isolation (Finkelstein, 1994). One recent study found that the protective behaviors practiced by disenfranchised women were dependent on their level of self-esteem and the degree to which they perceived life as controllable and meaningful (Nyamathi et al., 1994). However, the social environments in which female IDUs live often do not contribute to their self-esteem or feelings of power in their surroundings. High rates of unemployment, unstable housing, and homelessness are common among these women. Some female injectors also experience physical and sexual abuse, characterized by drug-related violence and illegal activities (Worth et al.,1989).

For several reasons, sexual transmission of HIV from IDUs to their sex partners may present a greater risk for women than for men. Although both male and female IDUs are likely to have IDU partners, this possibility is particularly high among women (Mandell et al., 1994). One study showed that 75 to 90 percent of female IDUs have a male injection-drug-using partner, compared with 20 to 50 percent of male users who have female drug-using partners (Donoghoe, 1992).

Female IDUs who are sex partners of male IDUs also use sex as a way to obtain drugs (Donoghoe, 1992). According to one study, approximately 25 percent of female IDUs trade sex for either money or drugs (Saxon et al.,1991). The risk of HIV infection is increased when they also share needles with their sex partners. Injection-drug-using women may be less likely to use condoms with their sex partners than non-injecting women who have IDU sex partners (Cohen, 1991). In addition, the use of condoms by female IDUs with sex partners varies according to the type of sex partner (casual, primary, partners with which the IDU exchanges money or drugs). Among women participating in needle exchange programs, 60 percent who exchanged sex for money or drugs, 50 percent who had sex with casual partners, and 32 percent who had sex with primary partners reported "always" using a condom (Paone et al.,1995).

Research has shown also that a strong predictor for HIV seroconversion among female IDUs is engaging in woman-to-woman sex. It is likely that the reason for high seroconversion rates for these female IDUs is that the people with whom they inject drugs are more likely than other IDUs to be infected. Female IDUs who have sex with women are more likely than other female IDUs to share needles or syringes with male IDUs who have sex with men (Friedman et al., 1995).

Female sex partners of IDUs

According to the National Research Council, female sex partners of IDUs have been difficult to study and reach with prevention programs (Miller et al., 1990). These women are often difficult to identify, since they rarely belong to any unifying social group and may have very unstable living conditions.

Many female partners of IDUs may not be aware of their partner's injection practices or may be unwilling or unable to acknowledge this behavior. Women may fear the confrontation that might occur if drug use practices are openly addressed. Without recognition or acknowledgment of their partners' risky practices, these women may perceive their risk as unrealistically low and have little reason or opportunity to use condoms.

Female crack users

The association between crack use and HIV infection is significantly stronger among women than among men (Edlin et al., 1994). Women who smoke crack frequently engage in sex work and often have a history of genital ulcer disease, making them more vulnerable to the acquisition or transmission of HIV. Female crack users who exchange sex for drugs or money to buy drugs also may not be able to negotiate condom use with their sex partners. Females who smoke crack and barter sex generally have degrading sexual experiences in which they are the subordinate partner and subject to abuse (Ratner, 1993). HIV prevention programs for these women must take into account this social dynamic.

Female sex workers

A study of 1,396 female sex workers in six U.S. cities found an HIV seroprevalence of 12 percent, ranging from zero to nearly 50 percent, depending on the city and the level of injection drug use (CDC, 1987). Street sex workers are likely to be dependent on drugs and alcohol and therefore more vulnerable to HIV infection (Alexander, 1992). Many are poor or homeless and have a history of child abuse. Female injection drug users who trade sex for money or drugs are more likely to share needles than female injectors who do not engage in sex trading, and are less likely to use new needles or to clean old ones (Kail et al., 1995).

The circumstances of subordination and powerlessness in which many sex workers live increase their vulnerability to HIV infection. For example, if business is slow, if they are desperate for money to buy drugs, or if a client offers substantial money, a sex worker may agree to unprotected sex. Violent clients may force unsafe sex. In many cities, police confiscate condoms when they arrest or stop sex workers, and they may have difficulty getting replacements (CAPS, 1996).

Regardless of whether a female drug user is an injector or non-injector, a sex trader or commercial sex worker, the power imbalance they may experience with men may make it difficult for women to change their sexual behaviors. Prevention planners and program managers should be sensitive to the unique issues experienced by such women and support and develop programs that adequately address the multiple obstacles faced by women at risk for HIV infection.

Men Who Have Sex with Men (MSM) and Bisexual Men

Relatively little HIV/AIDS research has focused on male IDUs who have sex with men or who are bisexual. AIDS case data indicate that men in this dual risk group are at substantially increased risk for AIDS compared with those reporting either risk behavior alone. According to CDC this subpopulation of IDUs comprises 6 percent of all AIDS cases, 10 percent of AIDS cases occurring in MSM, and 21 percent of AIDS cases occurring in IDUs (CDC, 1996). One analysis of MSM and bisexual men participating in the San Francisco Men's Health Study found that this subpopulation was more likely to report high-risk sexual activity at study entry than were non-IDU MSM and bisexual men (Stallet al., 1989). Another study, which looked at male sex workers in San Francisco, shows the significant risk for these men by documenting high rates of injection and needle sharing among hustlers and call men in communal settings such as shooting galleries and sex clubs (Waldorf, 1994). In addition, the increased use by MSM IDUs of methamphetamine, which induces heightened sexual needs, has increased their risk for HIV through both needle sharing and high-risk sexual behavior.

The Homeless and Mentally Ill

There are significant overlaps among chronic mental illness, substance abuse, unsafe sexual behavior, and homelessness. For example, surveys and exploratory studies of drug-related behavior consistently indicate that the prevalence of injection drug use increases as housing becomes more unstable (NIDA, 1990). As many as 30 percent of homeless adults may be substance abusers (Schutt et al., 1992). Reported rates of alcohol problems average 50 percent, with evidence that homeless, alcohol-dependent adults display more severe forms of alcoholism (Fischer et al., 1991; Schutt et al., 1992).

Overall, homeless adults have higher rates of HIV seroprevalence than do the general population. This is especially true in areas of high HIV prevalence. Data from two New York City psychiatric hospitals found about a 5 percent seropositivity rate among homeless, mentally ill patients, compared with a rate for the general population in New York City of less than 3 percent (Cournos et al., 1991). One sample of non-hospitalized homeless psychiatric patients in a New York City homeless shelter for males showed that almost one-fifth were HIV positive (Susser et al., 1993). In Miami, 9.8 percent to 14.3 percent of homeless persons entering clinics were seropositive (Greer et al., 1989).

A survey of homeless adults entering a storefront medical clinic found that over two-thirds were at risk for HIV infection from various sources, including unprotected sex with multiple partners, injection drug use, sex with an IDU partner, or exchanges of unprotected sex for money or drugs. Almost half reported at least two risk factors combined, and one-fourth reported three or more risk factors (St. Lawrence et al., 1995). Along with facing multiple risks for HIV, many homeless people find it hard to form safe and stable intimate relationships because of their drug use, mental illness, violence, or transient living situations. For example, a study of homeless women found that almost all had been exposed to battery, and over half to rape. (Fisher et al., 1995).

Incarcerated Persons and Parolees

Drug offenses account for the single largest number of federal crimes for which people are incarcerated (Polonsky, 1994). In 1991, almost 80 percent of state prison inmates reported using illicit drugs at some time (DOJ, 1993). High rates of HIV infection occur in this population, with female inmates, inmates age 25 or younger, and African American and Hispanic inmates having the highest rates of infection (Polonsky, 1994). As reported by the National Institute of Justice in 1994, the AIDS incidence rate for people in correctional facilities (aggregated across all facilities) was 518 per 100,000, up from 392 per 100,000 in 1992-93, as compared to 41 per 100,000 in the general population of the U.S. (DOJ, 1994). Additional data show that the overall rate of confirmed AIDS among the nation's prison population (0.52 percent) was more than seven times the rate in the general population (0.07 percent) (DOJ, 1996). In 1991, only 1 percent of federal inmates who had moderate to severe drug abuse problems had received appropriate treatment; for those who did complete treatment, there were no aftercare services in place to help them remain drug-free when reentering the community (U.S. House of Representatives, 1991). HIV prevention planners and program managers need to work with the judicial and correctional systems, including the drug courts that exist in some cities, to support and plan programs for HIV risk reduction and drug-free living for paroled and released inmates and for correctional staff.

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