High-Risk Behaviors in Women Who Use Crack: Knowledge of HIV Serostatus and Risk Behavior

https://doi.org/10.1016/j.annepidem.2007.01.029Get rights and content

Purpose

To determine whether crack cocaine-using women who are aware of their HIV serostatus have made modifications in risk behaviors, we compared known HIV-positive (HIV+) and HIV-negative (HIV−) users with respect to sexual risk behaviors, prevalence of sexually transmitted infections (STIs) and vaginitis, and correlates of unprotected sex.

Methods

We used a cross-sectional design with street outreach, recruitment, and interviews of sexually active crack cocaine using women. Women received testing for HIV, STIs, and vaginitis.

Results

Sixty-one HIV+ and 117 HIV− women were enrolled. HIV+ women were significantly more likely to be African-American. There were no significant differences in drug use, types of sexual partners, number of paying partners, attitudes regarding condoms, or STI diagnoses. HIV+ women were less likely to engage in unprotected sex compared with HIV− women (56% vs. 75%, adjusted odds ratio [AOR], 0.36; 95% confidence interval [CI], 0.13–0.99). Among HIV+ women, unprotected sex was negatively associated with stronger beliefs regarding the protective value of condoms (AOR, 0.07; 95% CI, 0.01–0.67) and concurrent injection-drug use (AOR, 0.19; 95% CI, 0.04–0.99).

Conclusions

Although the majority of crack using HIV+ crack using women in this sample continued to engage in high-risk sexual activities, they were less likely to do so than HIV− women. Interventions targeting this population are needed.

Introduction

Increasing individuals' knowledge of their human immunodeficiency virus (HIV) serostatus to reduce high-risk sexual behaviors among individuals known to be HIV infected (HIV+) is an important HIV-prevention goal in the United States (1). Compared with HIV-seronegative (HIV−) women, HIV+ women report more frequently that they are abstinent or use condoms consistently 2, 3. However, subpopulations of HIV+ women, such as inner-city crack cocaine users, have been noted to engage in high-risk sexual activities, including the exchange of sex for money and drugs 4, 5, 6, as do their HIV− counterparts, who have a risk for acquiring HIV infection equal to that of men who have anal intercourse in the same population (7). Because crack cocaine use is associated with both delayed entry into HIV primary care and reduced medication adherence 8, 9, HIV+ crack-using women are likely to have high viral loads and are at high risk of transmitting HIV to sexual partners (10). In addition, the use of crack cocaine is associated with high rates of sexually transmitted infections and vaginitis 11, 12, which increase the efficacy of HIV transmission (13). Thus, crack-using women are an important group affecting the spread of the HIV epidemic in their communities because of the high risks of becoming infected as well as transmitting to others 7, 14.

Although it is widely acknowledged that drug users engage in more high-risk behaviors than nondrug users, several studies have shown that some HIV+ drug users attempt to reduce high-risk sexual behaviors 15, 16, 17. Among HIV+ intravenous drug users who consistently use condoms to protect regular sexual partners from infection, this has been called “informed altruism” (18). However, other studies have shown HIV+ drug users to be especially resistant to reducing sexual risk behaviors 19, 20, perhaps because of social and structural constraints imposed by poverty, unemployment, low levels of education, and addiction (21).

Little attention has been devoted to examining whether knowledge of HIV+ serostatus has led to modification of risk behaviors among seropositive crack cocaine-using women compared with that of their HIV− counterparts. Knowledge of the impact, if any, of HIV seropositivity self awareness on behavior and attitudes is important for the development of interventions to decrease risk behaviors in this population. In the present study, we compared a sample of HIV+ and HIV− crack-smoking women who were aware of their HIV serostatus with respect to demographics, sexual behaviors, normative beliefs regarding condoms and condom use, and the prevalence of sexually transmitted infections and vaginitis. We also examined correlates of unprotected sex among HIV+ and HIV− crack using women. We hypothesized that, given the highly addictive nature of crack and the social disenfranchisement of these women, risk behaviors would not be significantly reduced in HIV+ users compared with HIV− users.

Section snippets

Study Participants

Street outreach workers in Miami, Florida, located, screened, and recruited participants in areas known to have women with a high prevalence of drug use and HIV to participate in this cross-sectional study. Eligible participants were female, at least 18 years of age, English-speaking, self-reported having vaginal or anal sex in the past 30 days, and self-reported having smoked crack or snorted or injected cocaine or heroin in the last 30 days and having not been in drug treatment in the last 30

Demographics

Two hundred thirty-three drug-using women were enrolled in the study between July 2000 and September 2001. Twenty-two women who had not used crack in the last 30 days, 15 women with discordant results between their answer as to whether they were HIV+ and their test results, as well as 18 women who were unsure of their HIV status, were excluded from the analysis. One hundred seventy-eight women (61 HIV+ and 117 HIV−) were included in the analysis. Although HIV+ women were significantly more

Discussion

We found that, among crack-using women aware of their HIV serostatus, there were no significant differences in illicit drug or alcohol use, exchanging sex for drugs or money, or prevalence of STIs or vaginitis between HIV− and HIV+ women in this sample. Although the majority of HIV+ women reported unprotected sex, they were significantly less likely to do so compared with HIV− women. These data suggest that knowledge of HIV+ serostatus has had some impact on the risk-taking behaviors of

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    This work was funded by the Minority Supplement to National Institute on Drug Abuse #R01 DA09953 “Miami injecting drug users and their sexual risk for HIV.”

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