HIV Risk Practices of Male Injecting-Drug Users Who Have Sex with Men -- Dallas, Denver, and Long Beach, 1991-1994

As of June 1995, a total of 31,024 cases of acquired immunodeficiency syndrome (AIDS) had been reported in the United States among male injecting-drug users (IDUs) who also reported sexual contact with other men (1). Although male IDUs who report male sex partners have accounted for 7% of all AIDS cases and for 21% of cases reported among IDUs, the characteristics and risk practices of male IDUs who have sex with men (MSM) have not been clearly determined (2-4). To better characterize this group of men with multiple risk factors for human immunodeficiency virus (HIV) infection, data collected during February 1991 through June 1994 from three sites -- Dallas; Denver; and Long Beach, California -- were analyzed as part of the CDC-sponsored AIDS Community Demonstration Projects (5,6). This report summarizes results of that analysis.

The Community Demonstration Projects included interviews of male IDUs conducted in neighborhoods with a high prevalence of drug use. Trained interviewers approached potential respondents on the street to administer a screening interview that assessed recent HIV risk practices (i.e., needle sharing during the preceding 60 days or vaginal or anal intercourse during the preceding 30 days). At-risk persons also completed a second interview about perceived risk for HIV infection, drug-injection practices, and sexual behavior. A cash incentive or grocery vouchers were provided for completing each interview. This report presents data for men who reported injecting drugs during the preceding 30 days.

Nearly all (1697 {93%} of 1820) of the sexually active male IDUs who were screened completed the second interview. Of these, 297 (18%) reported having had one or more male sex partners during the preceding 30 days. The percentage of MSM IDUs varied by city (Denver, 28%; Dallas, 22%; and Long Beach, 10%). Nearly two thirds (178 {60%} of 297) of MSM IDUs self-identified as bisexual, 97 (33%) as heterosexual, and 15 (5%) as homosexual; seven (2%) were undecided about their sexual identity. Most MSM IDUs in this sample were black (192 {65%} of 297), aged greater than or equal to 30 years (224 {75%}), and recruited at the Denver site (167 {56%}).

A total of 224 (75%) MSM IDUs had traded sex for money or drugs during the preceding 30 days. Almost all (283 {95%}) had had more than one sex partner during the preceding 30 days. The mean number of male partners during the preceding 30 days was 3.8 (range: 1-41; standard deviation {SD}: plus or minus 5.6). Most (263 {89%}) reported having one or more (mean: 4.5, range: 0-61, SD: plus or minus 6.4) female sex partners. A total of 148 (50%) reported having had a partner whom they identified as their main or primary sex partner. Of those with a main partner, 110 (74%) of 148 indicated this partner was female.

Nearly all MSM IDUs (290 {98%}) reported having ever had vaginal intercourse. During the preceding 30 days, 267 (90%) had had vaginal intercourse with main and/or other partners. Of those with a female main partner, 13 (12%) of 105 reported using a condom the last time they had vaginal intercourse; of those who had had vaginal sex with someone they did not consider to be their main partner (i.e., non-main partner), 30 (13%) of 233 had used a condom at last intercourse.

Nearly all (282 {95%}) had ever engaged in anal intercourse; 201 (71%) had had anal intercourse with both men and women, 51 (18%) with men only, and 30 (11%) with women only. Most (250 {84%} of 297) had also had anal intercourse during the preceding 30 days. Data regarding condom use during anal intercourse during the preceding 30 days were collected for a subset of respondents. Eight (23%) of 35 of those with a male main partner and eight (20%) of 41 of those with a female main partner used a condom the last time they had anal intercourse with this partner. Among MSM IDUs with non-main partners, 53 (27%) of 200 used a condom the last time they had anal intercourse.

During the preceding 60 days, 250 (86%) of 292 MSM IDUs reported having shared syringes or other paraphernalia used to prepare or inject illicit drugs. Less than one third (73 {29%} of 248) indicated that the last time they shared injection equipment they used bleach to clean their needle or syringe.

Reported by: RJ Wolitski, MA, N Corby, PhD, J Wood, California State Univ, Long Beach. M Fishbein, PhD, Univ of Illinois, Champaign. G Goldbaum, MD, Seattle-King County Dept of Health, Washington. M Krepcho, PhD, Dallas County Health Dept, Texas. K Rietmeijer, MD, Denver Dept of Public Health, Colorado. J Sheridan, Conwal Inc, Falls Church, Virginia. S Tross, PhD, National Development and Research Institute, New York City. Behavioral Intervention Research Br, Div of HIV/AIDS Prevention, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Approximately 18% of male IDUs interviewed at the three sites in this study reported having had sex with another male during the previous 30 days -- a rate higher than that reported for a national sample of men aged 20-39 years (7), but consistent with previous studies of male IDUs (2,4). Although these previous studies were based on convenience samples and the estimates probably were not representative of the total population of IDUs, the range for the prevalence of MSM activity among IDUs is similar to that documented in the three sites in this report.

In this study, the prevalences of drug-injection and sexual practices associated with the transmission of HIV infection were high among MSM IDUs, including recent sharing of injection equipment, trading of sex for money or drugs, engaging in anal sex, and having had multiple sex partners. Because such practices increase the risk for acquiring and/or transmitting HIV infection to needle-sharing and sex partners, intervention programs for MSM IDUs should address both drug-related and sexual risk factors.

The findings in this report also indicate that sexual self-identification as heterosexual or homosexual may not correspond with sexual practices. Assessment of risk for HIV infection should be based on behavior, regardless of self-identification. Self-identification as heterosexual or bisexual, however, may be useful in planning and conducting intervention activities (8). For example, efforts to provide preventive measures to MSM IDUs who do not self-identify as homosexual may need to be directed through a variety of settings because such men may ignore or resist messages that appear to be targeted toward men who are homosexual.

The use of neighborhood-based samples in Dallas, Denver, and Long Beach may have resulted in some biases. For example, some important subgroups (e.g., amphetamine users and men who self-identify as homosexual) probably were undersampled, while other groups (e.g., men who traded sex for money or drugs) may have been oversampled. Although these potential sampling biases may have influenced the patterns of HIV risk in this study, the extent to which these biases affected the estimates of HIV risk among MSM IDUs could not be assessed.

The development of programs for preventing HIV transmission among MSM IDUs requires that public health agencies and local community-planning groups characterize the risk for this group and examine available data from AIDS case reports, HIV counseling and testing sites, and behavioral surveillance surveys. Determinants for risk that may vary by location include demographic characteristics, patterns of sexual practices and of substance use, and access to HIV-prevention services.

References

1. CDC. HIV/AIDS surveillance report. Atlanta: US Department of Health and Human Services, Public Health Service, 1995:1. (Vol. 6, no. 7).

2. Lewis DK, Watters JK. Sexual behavior and sexual identity in male injection drug users. J Acquir Immune Defic Syndr 1994;7:190-8.

3. Paul JP, Stall R, Davis F. Sexual risk for HIV transmission among gay/bisexual men in substance abuse treatment. AIDS Education and Prevention 1993;5:11-24.

4. Ross MW, Wodak A, Gold J, Miller ME. Differences across sexual orientation on HIV risk behaviors in injecting drug users. AIDS Care 1992;4:139-48.

5. CDC. Community-level prevention of HIV infection among high-risk populations: methodology and preliminary findings from the AIDS Community Demonstration Projects. MMWR Supplement (in press).

6. O'Reilly KR, Higgins DL. AIDS Community Demonstration Projects for HIV prevention among hard-to-reach groups. Public Health Rep 1991;106: 714-20.

7. Billy JO, Tanfer K, Grady WR, Klepinger DH. The sexual behavior of men in the United States. Fam Plann Perspec 1993;25:52-60.

8. Doll LS, Beeker C. Male bisexual behavior and HIV risk in the United States: synthesis of research with implications for behavioral interventions. AIDS Educ Prev (in press).

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