Sexual Partners Of Injection Drug Users Research Articles

Short Communication: HIV Prevalence and Risk Behavior Among Injection Drug Users and Their Sex Partners in Two Russian Cities

The HIV epidemic in Russia remains concentrated mostly among injection drug users (IDUs). Little is known about the extent to which sexual partnerships are the bridge between IDUs and the general population and create the potential for generalizing the epidemic. IDUs in two Russian cities, Novosibirsk and Ivanovo (N=593), were recruited via respondent-driven sampling. A modified one-step snowball strategy was used to recruit IDU's sex partners who do not themselves use drugs (PIDU, N=82). Sexual behaviors of all participants were assessed using an interviewer-administered questionnaire. All participants provided blood specimens for HIV and hepatitis C virus (HCV) testing. HIV and HCV prevalence among IDUs was 34.0% and 44.4% in Ivanovo and 3.8% and 54.3% in Novosibirsk. HIV prevalence among PIDUs was 6.8% in Ivanovo and 8.7% in Novosibirsk. In both cities large proportions of IDUs reported sexual partnerships with non-IDUs-49.7% in Ivanovo vs. 62.7% in Novosibirsk (p≤0.001) and fewer than one in four IDUs reported constant condom use in such partnerships. This pilot study shows that two IDU populations with a significantly different HIV prevalence both form sexual partnerships with non-IDUs and practice unsafe sexual behavior within such types of partnerships. However, the proportion of PIDUs who form partnerships with other non-IDUs that therefore could lead to a generalization of the epidemic is very different between the two cities and this difference needs to be considered when estimating the spread of HIV into the general population. Unsafe sexual behavior and HIV testing should be specific targets for prevention activities for IDUs and their sex partners in Russia.

Risk for Heterosexual HIV Transmission Among Non-Injecting Female Partners of Injection Drug Users in Estonia

The HIV epidemic in Estonia, as with other eastern European countries, is currently concentrated among injection drug users (IDUs). Non-IDUs who have IDU sex partners could serve as a potential bridge in an expanding epidemic. We applied HIV transmission modelling to data collected from non-IDU/IDU heterosexual couples in Kohtla-Järve, Estonia to estimate HIV risk from IDUs to their sex partners based on self-reported sexual behaviors shared by the couple. IDUs and their current main non-injecting sex partners were recruited for an interviewer-administered survey and HIV testing. Bernoulli modelling techniques were applied to estimate the risk of HIV transmission (incidence) among HIV negative non-injecting female partners of male IDUs. The estimated HIV incidence in this population of non-injecting women with only main sexual partners in the last 6months ranged from 3.24 to 4.94 HIV seroconversions per 100 person years depending on the value used in the models for the per act transmission rate during acute stage infection. Non-IDUs who have IDU sex partners are at high risk for HIV and could serve as a potential bridge to a more generalized epidemic. Whether this might lead to an expansion of the HIV epidemic beyond core groups in Estonia or other Eastern European countries warrants closer study.

Age at First Alcoholic Drink as Predictor of Current HIV Sexual Risk Behaviors Among a Sample of Injection Drug Users (IDUs) and Non-IDUs who are Sexual Partners of IDUs, in St. Petersburg, Russia

This study investigates whether age at first alcoholic drink is associated with sexual risk behaviors among injection drug users (IDUs) and non-IDUs who are sexual partners of IDUs in St. Petersburg, Russia. A path analysis was used to test a model of age at first drink, age at sexual debut, age at first drug use, current substance use patterns and current sexual risk behaviors among 558 participants. Results revealed that age at first drink had an effect on multiple sex partners through age at sexual debut and injection drug use, but no effect on unprotected sex. Age at first drug use was not related to sexual risk behaviors. Investigation of age of drinking onset may provide useful information for programs to reduce sexual risk behaviors and injection drug use. Different paths leading to unprotected sex and multiple sexual partners call for different approaches to reduce sexual risk behaviors among this population.

Comparing sexual risks and patterns of alcohol and drug use between injection drug users (IDUs) and non-IDUs who report sexual partnerships with IDUs in St. Petersburg, Russia

BackgroundTo date, the great majority of Russian HIV infections have been diagnosed among IDUs and concerns about the potential for a sexual transmission of HIV beyond the IDU population have increased. This study investigated differences in the prevalence of sexual risk behaviors between IDUs and non-IDUs in St. Petersburg, Russia and assessed associations between substance use patterns and sexual risks within and between those two groups.MethodsCross-sectional survey data and biological test results from 331 IDUs and 65 non-IDUs who have IDU sex partners were analyzed. Multivariate regression was employed to calculate measures of associations.ResultsIDUs were less likely than non-IDUs to report multiple sexual partners and unprotected sex with casual partners. The quantity, frequency and intensity of alcohol use did not differ between IDUs and non-IDUs, but non-IDUs were more likely to engage in alcohol use categorized as risky per the alcohol use disorders identification test (AUDIT-C). Risky sexual practices were independently associated with monthly methamphetamine injection among IDUs and with risky alcohol use among non-IDUs. Having sex when high on alcohol or drugs was associated with unprotected sex only among IDUs.ConclusionsGreater prevalence of sexual risk among non-IDUs who have IDU sex partners compared to IDUs suggests the potential for sexual transmission of HIV from the high-prevalence IDU population into the general population. HIV prevention programs among IDUs in St. Petersburg owe special attention to risky alcohol use among non-IDUs who have IDU sex partners and the propensity of IDUs to have sex when high on alcohol or drugs and forgo condoms.

Potential Bridges of Heterosexual HIV Transmission from Drug Users to the General Population in St. Petersburg, Russia: Is it Easy to be a Young Female?

The epidemic of HIV in St. Petersburg, which is currently concentrated among injection drug users (IDUs), may be penetrating into the general population. Non-IDUs who have IDU sex partners (SP) could be potential bridges in an expanding epidemic. To investigate potential bridges, we accrued a convenience sample of 288 non-IDUs whose HIV diagnosis was attributed to sexual transmission and we determined the proportion that had IDUs among their SP. Having IDU SP ever (lifetime) and IDU SP in the last year were the key variables for the analysis of potential bridges in this study. The interaction of gender and age was found to be a significant predictor of having lifetime IDU SP (p = 0.006, chi (2) test) and IDU SP in the last year (p = 0.05, chi (2) test): females aged 26 and younger were more likely to have both lifetime IDU SP and IDU SP in the last year. Among the group of young females, 46% reported ever having an IDU SP. Out of young women reporting ever having an IDU SP, 85% also reported at least one lifetime non-IDU SP. Among the females aged 26 or younger, a lower level of education (odds ratio [OR] = 2.7, confidence interval [CI] = 1.1-6.7), being born in St. Petersburg (OR = 2.9, CI = 1.2-7.2), and alcohol use in the last 30 days (OR = 3.5, CI = 1.3-9.6) were significant correlates for ever having had an IDU SP. Urgent efforts are necessary to expand HIV prevention to target the potential bridging population to prevent further transmission.

The Impact of Sex Partners' HIV Status on HIV Seroconversion in a Prospective Cohort of Injection Drug Users

The identification of individuals at highest risk of HIV infection is critical for targeting prevention strategies. We evaluated the HIV status of the sex partners of injection drug users (IDUs) and rates of subsequent HIV seroconversion among a prospective cohort study of IDUs. We performed an analysis of the time to HIV infection among baseline HIV-negative IDUs enrolled in the Vancouver Injection Drug Users Study. IDUs were stratified based on whether or not they reported having an HIV-positive sex partner. Kaplan-Meier methods were used to estimate cumulative HIV incidence rates, and Cox regression was used to determine adjusted relative hazards (RHs) for HIV seroconversion. Of 1013 initially HIV-negative IDUs, 4.8% had an HIV-positive partner at baseline. After 18 months, the cumulative HIV incidence rate was significantly elevated among those who reported having an HIV-positive sex partner (23.4% vs. 8.1%; log-rank P < 0.001). In a Cox regression model adjusting for all variables that were associated with the time to HIV infection in univariate analyses, including drug use characteristics, having an HIV-positive sex partner (RH = 2.42 [95% confidence interval: 1.30 to 4.60]; P = 0.005) remained independently associated with time to HIV seroconversion. Having an HIV-positive sex partner was strongly and independently associated with seroconversion after adjustment for risk factors related to drug use. Our findings may aid public health workers in their efforts to identify IDUs who should be targeted with education and prevention efforts and indicate the need for ongoing development of prevention interventions for IDU sex partners who are HIV discordant.

Sexual HIV transmission in the context of injection drug use: implications for interventions

In recent years, there has been increased awareness of sexual HIV transmission between injection drug users (IDUs) and from IDUs to the ‘‘general’’ population. This commentary will highlight both aspects of these HIV transmission dynamics, with special attention on the implications for interventions and future research. It is argued that, based on the existing literature, a narrow focus on injection-related risks is an ineffective prevention strategy, regardless of the stage of the HIV epidemic. Interventions that target specific subgroups warrant attention of high-risk IDUs such as those who are sex workers, MSM, incarcerated and/or HIVinfected. Future research should expand efforts in behavioural surveillance to keep abreast of potential changes in HIV/STD transmission dynamics and inform efforts to guide policies. In early landmark studies of IDU populations, most HIV infections appeared to be due to parenteral risks (Des Jarlais, Friedman & Hopkins, 1985; Chaisson et al., 1987; Schoenbaum et al., 1989), leading to the presumption that sexual risks among IDUs were negligible. Other studies suggested that sexual risks were present, but were overshadowed by parenteral risks (van Ameijden & Coutinho, 1998; Marx et al., 1991; Battjes et al., 1990). Recent studies have shown otherwise. In particular, in a 10 year prospective study among IDUs in Baltimore where HIV prevalence was initially high ( /25%), predominant risk factors among males included not only needle-sharing, but sex with men. Among females, factors consistent with high risk heterosexual activity (e.g. having a recent STD and an IDU sex partner) outweighed drug-related risks (Strathdee et al., 2001). Results based on a series of crosssectional studies among young IDUs who were new initiates to injection drug use in Baltimore were similar, suggesting that sexual risks may be important throughout the span of an injection drug use career (Strathdee et al., 2002). Moreover, in a prospective study of IDUs in San Francisco, both homosexual activity and female sex work were associated with HIV seroconversion (Kral et al., 2001), which underscores the consistency of these findings in both high and low HIV prevalence settings. Interestingly, in the latter study, females with IDU sex partners were less likely to seroconvert than other female IDUs, suggesting that the context of sexual partnerships involving IDUs likely influences the degree of risk. Surprisingly, interventions focused on IDUs have tended to overlook sexual risks. In a 1996 survey of needle exchange programmes in the US, Paone et al. reported that only 18% offered on-site STD testing and medical referrals (Paone et al., 1999). Similarly, substance abuse treatment programmes have seldom had a dual focus on injection and sexual risk reduction, which has likely accounted at least in part for reported inconsistencies in study findings of the impact of these interventions on sexual risk behaviours (MacGowan et al., 1997; Lollis et al., 2000; Avants et al., 2000). In a follow-up study of clients enrolled in methadone maintenance programmes in two US states, inconsistent condom use was significantly associated with enrollment in programmes where condoms were available only upon request and abstinence and monogamy between uninfected partners were promoted (MacGowan et al., 1997). These examples illustrate the extent to which a broader, integrated approach to risk reduction is needed in such settings. A recent meta-analysis of 33 intervention studies focused on reducing sexual risks among drug users found a 40% risk reduction overall, which justifies the need to incorporate these interventions into existing programmes that target high risk drug users (Semaan et al., 2002). * Tel.: /1-410-614-4255; fax: /1-410-955-1383. E-mail address: sstrathd@jhsph.edu (S.A. Strathdee). International Journal of Drug Policy 14 (2003) 79 /81

Distribution of HIV-1 subtypes seen in an AIDS clinic in Sao Paulo City, Brazil.

To determine the distribution of HIV-1 subtypes in Sao Paulo, Brazil. Samples were obtained from 80 consecutive HIV-1-infected individuals attending the Immunodeficiency Clinic at the University of Sao Paulo in 1993. Peripheral blood mononuclear cells (PBMC) were separated by Ficoll-Hypaque gradient and a portion was used for routine CD4 counts; the remainder were frozen. PBMC were proteinase-K-digested and DNA-purified by organic extraction. Samples were amplified for the env region of HIV, and envelope sequence subtypes determined by heteroduplex mobility analysis using prototypic subtypes as references. A subset of these were also sequenced through the C2-V3 region of env. A total 69 of 80 samples yielded env polymerase chain reaction product enabling subtype determination; samples that did not amplify were those with low DNA yields. Among 12 injecting drug users (IDU) or sexual partners of IDU, four were typed as clade F and eight as clade B. Forty-three homosexual men or female sexual partners of bisexual men were typed as clade B. The 14 additional cases without known risk factors were typed as clade B. These data suggest that subtype F is related to injecting drug use in Brazil.

Demographic and Behavioral Characteristics of Hispanic Female Sexual Partners of Injection Drug Users

This is a study of baseline demographic, drug, and sex risk behavior data collected on 1,370 Hispanic female sexual partners of injection drug users (IDUs) located in San Juan, Puerto Rico (n = 618), Juarez, Mexico (n = 600), and the continental United States (n = 152). The study found significant differences in the demographics within the three sites in terms of age, marital status, education, employment, and income source. Differences were also found in past history of drug use, past history of sexual risk behaviors, current drug use, and current sexual risk behaviors. Only 8.5% of the women in the study had used a condom within the last 30 days prior to study entrance. Over half had been sexually abused during adulthood. The study found a need for site-specific AIDS prevention interventions based on the demographics and risk behaviors within specific groups offemale sexual partners of IDUs. The study also demonstrates a need to address the issues of sexual and physical abuse for these women.

Reducing HIV Risk Behaviors: Perceptions of HIV Risk and Stage of Change

The HIV epidemic has had a dramatic impact on the lives of individuals, families, and communities around the world. Originally identified in homosexual men, HIV increasingly affects others, including: (1) those who inject drugs, (2) non-injection drug users who engage in unsafe sex, and (3) non-drug using heterosexuals who engage in high-risk sexual behaviors. The need for effective HIV prevention interventions is critical. All too often interventions have lacked sound theoretical frameworks. However, some attempts have been made to ground HIV risk behavior interventions in behavior theories such as: (1) the health belief model, (2) cognitive social learning theory, (3) the theory of reasoned action, and (4) the transtheoretical model of behavior change (TMBC). This paper describes an HIV prevention intervention that was developed from the TMBC model. The TMBC model hypothesizes stages of change. In this study, injection drug users (IDUs), crack cocaine users (CCUs), and female sexual partners of IDUs and CCUs identified their stage of change and were given an intervention based upon their identified stage. Baseline and post intervention follow-up data were obtained on participants' perceived stage and reported HIV sexual risk behavior. The data indicated that there was little congruence between perceived stage and reported risk. In spite of this incongruence, significant decreases in HIV risk behaviors were evidenced.

A Comparison of HIV Related Risk Behaviors of Street Recruited and Treatment Program Recruited Injection Drug Users

SUMMARY This paper compares the demographic traits and the risk behaviors of injection drug users (IDUs) not in treatment who were recruited into an AIDS risk reduction program in Miami, FL with attributes of IDUs who were clients of drug treatment programs. The majority of both IDU samples were male and in their 30's. Most street IDUs were African-American; a majority of treatment clients were White, non-Hispanic. Prevalence of HIV was high for African-Americans and Hispanics from both IDU samples. Prevalence of HIV was relatively low among both samples of White, non-Hispanic IDUs but somewhat higher among White street IDUs than among White treatment clients. Similar proportions of street and treatment IDUs injected daily, but street IDUs were more likely to share works, inject in shooting galleries, use crack and alcohol daily, have multiple sex partners and have IDU sex partners.

An experiential program to reduce AIDS risk among female sex partners of injection-drug users.

This article describes the development and implementation of an acquired immune deficiency syndrome (AIDS) intervention program for female sex partners of male injection-drug users. Four psychoeducational workshops were designed to motivate personal risk reduction, provide participants with necessary cognitive and behavioral skills, and enhance participants' perceived ability to enact positive changes in their lives. The development of the workshop modules was guided by traditional theories of health behavior change and social learning. Also included in the intervention are referral and advocacy services, personal risk reduction counseling, and human immunodeficiency virus (HIV) antibody testing. Preliminary results indicate that the program has made a significant impact on the AIDS risk of participants--91 percent of women who completed the program reported that they had made positive changes in their lives to reduce their risk of HIV infection.

HIV Antibody Testing in Young, Urban Adults

We surveyed men and women aged 21 to 34 years to determine the rates of human immunodeficiency virus (HIV) antibody testing in blacks and whites of diverse education levels in four US cities. Responses to the anonymous, mailed questionnaire were received from 90% of 777 white women, 64% of 734 black women, 79% of 677 white men, and 48% of 541 black men. The percentages reporting HIV testing for these four race-gender groups were 29%, 22%, 30%, and 38%, respectively. The percentages reporting testing that was voluntarily sought (ie, not in connection with blood donation, military service) were 16%, 14%, 18%, and 22%, respectively. In each race-gender group, roughly half of those who had not been tested said they "might have a blood test for the AIDS virus in the future". Education level was not correlated with HIV-testing frequency. Blacks were significantly less likely than whites to be aware of "a blood test that can detect the AIDS virus infection" (58% vs 77%), but blacks who knew of the test were more likely than whites to have been tested (47% vs 37%). Eleven percent of subjects reported at least one major risk factor for HIV infection. In these people, HIV testing was most common among homosexually active men (56% tested; 52% voluntarily sought), intermediate among injection drug users (40% tested; 31% voluntarily sought), and least common among the sexual partners of injection-drug users (21% tested; 11% voluntarily sought). Health education programs need to communicate the availability of, and need for, anonymous HIV testing.

HIV antibody testing in young, urban adults

We surveyed men and women aged 21 to 34 years to determine the rates of human immunodeficiency virus (HIV) antibody testing in blacks and whites of diverse education levels in four US cities. Responses to the anonymous, mailed questionnaire were received from 90% of 777 white women, 64% of 734 black women, 79% of 677 white men, and 48% of 541 black men. The percentages reporting HIV testing for these four race-gender groups were 29%, 22%, 30%, and 38%, respectively. The percentages reporting testing that was voluntarily sought (ie, not in connection with blood donation, military service) were 16%, 14%, 18%, and 22%, respectively. In each race-gender group, roughly half of those who had not been tested said they "might have a blood test for the AIDS virus in the future." Education level was not correlated with HIV-testing frequency. Blacks were significantly less likely than whites to be aware of "a blood test that can detect the AIDS virus infection" (58% vs 77%), but blacks who knew of the test were more likely than whites to have been tested (47% vs 37%). Eleven percent of subjects reported at least one major risk factor for HIV infection. In these people, HIV testing was most common among homosexually active men (56% tested; 52% voluntarily sought), intermediate among injection drug users (40% tested; 31% voluntarily sought), and least common among the sexual partners of injection-drug users (21% tested; 11% voluntarily sought). Health education programs need to communicate the availability of, and need for, anonymous HIV testing. (Arch Intern Med. 1992;152:397-402)