Behavioral risk factors of human immunodeficiency virus infection among intravenous drug users and implications for preventive interventions

Risk behaviors for HIV infection in relation to drug and sexual activities among 262 intravenous drug users (IVDUs) from methadone clinics in New York City were investigated using a structured questionnaire in 1986. The overall seroprevalence rate was 60.1 per cent. Intravenous heroin and cocaine users were found to be significantly more likely to be HIV positive than those who used heroin and cocaine intranasally. Among female IVDUs, excluding prostitutes (defined by self-report of sex for money or drugs), the HIV positive participants reported higher numbers of sex partners than those participants who were HIV negative. The female IVDUs who reported prostitution during the last 12 months were less likely to be HIV positive than those who did not. All males who reported passive anal and oral sex without using condoms during the last 12 months were found to be HIV positive. All female prostitutes who reported use of condoms during the last 12 months were found to be HIV negative. Interventions in methadone maintenance programs should focus on the IVDUs who are still using heroin, cocaine, and marijuana; sexually active females; and those IVDUs not using condoms (particularly among prostitutes).     

High-risk sexual behaviors of intravenous drug users in- and out-of-treatment: implications for the spread of HIV infection.

This paper examines the sexual behaviors of 255 intravenous drug users (IVDUs) to assess the potential for the sexual transmission of HIV and to examine differences in sexual behaviors between in- and out-of-treatment IVDUs. In-treatment subjects (N = 152) were a random sample of clients at a large, publicly funded methadone maintenance program. Out-of-treatment subjects (N = 103) were recruited through a chain referral technique, using the in-treatment subjects. Forty-five percent of the study subjects reported multiple partners and 32% reported exchanging sex for money or drugs in the preceding 6 months. Fifty-three percent reported no use of condoms. After controlling for demographic differences between the in- and out-of-treatment groups, out-of-treatment IVDUs reported significantly more partners than in-treatment IVDUs (4.6 vs 2.3, significant t < 0.01), and more often had exchanged sex for money or drugs (44 vs 26%, relative odds 1.8, p < .05). In- and out-of-treatment subjects did not differ with respect to condom use. We conclude that IVDUs both in- and out-of-treatment continue to be at risk of contracting and spreading HIV infection through sexual behaviors, and that being in drug treatment is associated with a lower incidence of high risk sexual behaviors.     

Age at first injection and HIV risk among intravenous drug users.

The relationship of age at first injection and HIV risk was explored in a nonblinded HIV seroprevalence study of intravenous drug users (IVDUs) admitted to methadone treatment in seven United States cities between February 1987 and June 1989. Comparisons were made of IVDUs who began injecting as adolescents, young adults, and adults in terms of drug use and sexual HIV risk behaviors and HIV serostatus. Early injectors consistently reported higher levels of drug-using risk behaviors (e.g., frequency of injection, frequency of needle sharing, and use of shooting galleries), and were more likely to be HIV seropositive. Among females, early injectors were also more likely to report sexual risk behaviors (e.g., multiple sex partners, prostitution). The relationship of age at first injection with selected risk behaviors and HIV serostatus was independent of subjects' age at interview, gender, and race/ethnicity. This study suggests that adolescent injectors are an important target group for HIV prevention efforts.     

Heterosexual transmission of human immunodeficiency virus among intravenous drug users

To examine sexual transmission of human immunodeficiency virus (HIV) among heterosexual intravenous drug users (IVDUs), HIV antibody status of IVDUs with intravenous drug-using sexual partners (IVSPs) was compared with that of IVDUs with no IVSPs. Initial bivariate analyses indicated IVDUs with IVSPs were more likely to be HIV antibody-positive than those with no IVSPs. Analyses by gender indicated that this relationship held for men but not women. IVDUs with IVSPs also differed from those without IVSPs demographically, in drug use, and in other sexual behaviors. When effects of other variables were controlled, no statistically significant relationship was found between injection history of sex partners and HIV status for the total sample or separately for men or women.     

AIDS-related behavior and attitudes among i.v. drug users in Greece.

Risk-taking behavior was investigated in 140 intravenous drug users to identify possible factors accounting for the low HIV seroprevalence rate in Greek intravenous drug users (IVDUs). High-risk drug using and sexual practices were reported by the majority. Awareness of the risk of HIV infection was low. One-third claimed to have changed risk behaviors in both drug use and sexual practices after the appearance of AIDS. Several drug use, mental health, criminal behavior, and sociodemographic factors were correlated with high risk behavior and reported change. Low HIV seroprevalence appears to be due to delayed invasion of the virus and not to the behavior of IVDUs.     

Trends of HIV-1 risk reduction among initiates into intravenous drug use 1982-1987

To assess how injection practices may have changed during the course of the AIDS epidemic, active intravenous drug users (IVDUs) recruited from the community were asked to report year of first injection as well as specific details about the first 3 months after initial injection: frequencies of injection, using sterile needles, sharing needles and other equipment. For the analysis, the users were sorted into successive cohorts of initiation (by year of first injection), and tests for trends were completed using Mantel-Haenszel statistics. Among the 421 IVDUs who reported first injection between 1982 and 1987, the use of new sterile needles to self-administer drugs increased (p less than .05) along with its corollary behavior (i.e., using equipment one is sure that no one else had used before). Conversely, there was a decrease in the proportion of those who always used equipment previously used by another IVDU (p less than .05) and a decrease in the number of needle-sharing partners (p less than .01). Over the 6 years, heroin as first drug decreased and cocaine increased (p less than .01). Although these data are from a cross-sectional interview study, they suggest a shift toward lower risk practices among new IVDUs between 1982 and 1987. The shift from heroin to cocaine is compatible with other evidence on the cocaine epidemic.     

Sexually transmitted diseases in a population of intravenous drug users: association with seropositivity to the human immunodeficiency virus (HIV)

The association between human immunodeficiency virus (HIV) seropositivity and a history of sexually transmitted diseases (STDs), evidence of STDs on physical examination, and sexual and drug use practices was studied in a population of 2921 intravenous drug users (IVDUs) in Baltimore during 1988 and 1989. Overall, 24.1% were HIV-seropositive at baseline, and 60% reported a history of an STD. A significant association was found between HIV seropositivity and a history of syphilis (P = .04); both were more frequent among homosexual/bisexual men than among heterosexual IVDUs. In multivariate analysis, a history of syphilis was independently associated with HIV seroprevalence in homosexual/bisexual male IVDUs, of whom 90% reported a history of sexual intercourse with women. Cocaine injection was independently associated with HIV seropositivity but not a history of syphilis on multivariate analysis. STDs, indicative of unsafe sex practices, are common in this population; efforts are needed to prevent sexual transmission of HIV infection among IVDUs and their sex partners.     

I.v. versus non-i.v. drug use and selected patient variables related to AIDS risk behaviors.

A sample of 206 drug users volunteered for a survey questionnaire of AIDS-related risk behaviors. The Risk Behavior Inventory (RBI) was used to elicit self-report information on risk behaviors including drug use, needle use, and sexual practices. Non-IV cocaine users reported less risk behaviors than patients involved in IV drug use. Nevertheless, non-IV users remained substantially at risk for HIV exposure because of sexual practices and sexual interaction with IV drug users. Multiple regression analysis indicated that method of drug administration (IV vs non-IV) was the major contributor of accountable variance in risk behaviors, while other patient variables, such as age, gender, educational level, employment, and marital status, did not contribute significantly to the explained variance.     

Needle sharing and high-risk sexual behaviors among IV drug users in Southern Thailand

This study sought to determine the prevalence of needle sharing and high HIV risk sexual behaviors and to identify characteristics associated with these practices in southern Thailand. Data were obtained using a structured questionnaire from 298 male intravenous drug users (IVDUs) seen in a methadone clinic during the previous year. The prevalence of HIV was 37%, and that of needle-sharing in the preceding months was 45%, although only 10% claimed to have had unsafe sex with a casual partner or prostitute in the same period. Determinants for needle sharing included shorter duration of drug injection, diminished knowledge of HIV prevention, a carefree attitude toward risk of HIV infection, and lower levels of income. Young single IVDUs with a low knowledge of HIV prevention were most likely not to use a condom. In conclusion, needle sharing among the study subjects was still a common practice, whereas high HIV risk sexual behavior was not. Attitudinal change may be necessary to reduce needle-sharing behavior and not just information on disease transmission.     

Effects of amphetamine on sexual behavior of male i.v. drug users in Stockholm--a pilot study.

Sexual behavior in connection with drug use and its implications for the risk of sexual transmission of human immunodeficiency virus (HIV) among intravenous drug users (IVDUs) was investigated in a pilot study of 29 men (who injected drugs more than once a week for at least 6 months) at the Remand Prison in Stockholm from November, 1989, to January, 1990. A structured interview focusing on sexual history and current sexual behavior with and without drugs was employed. The median age of the subjects was 32 years. Six were HIV-seropositive. The main drugs presently used were amphetamine (18 men), heroin (9 men) and cocaine (2 men). Of the 29 men, 27 had experience of sexual activity while using amphetamine. Of these, 23 reported that they became more sexually excited when on amphetamine, 21 reported intensified orgasms, and 23 reported that the drug prolonged intercourse. All 29 men had been sexually active, but only 6 of the amphetamine users had had more than 10 partners during the last 3 years. Condom use was very low; it was reported by only 3 men during their last intercourse with a causal partner. The findings suggest that sexual HIV transmission among IVDUs is a clear risk, especially among amphetamine users, and that education about condom use is urgent.     

AIDS risk behaviors and knowledge among heterosexual alcoholics and non-injecting drug users

The disinhibitory effects of abusable substances on sexual behavior and the increasing HIV prevalence among heterosexuals suggest that alcoholics and non-injection drug users may be at risk for HIV infection. We examined alcohol and non-injection drug use as AIDS risk factors, AIDS risk knowledge, and the effect of AIDS education upon voluntary HIV testing among 91 heterosexual male inpatients in a VA alcohol rehabilitation program. Questionnaire data revealed relationships between age, the use of alcohol, marijuana and intranasal cocaine just prior to sex and an increase in the number of female sexual partners. Use of alcohol just prior to sex was also associated with an increased number of unprotected sexual behaviors. AIDS risk knowledge in our sample was comparable to norms from previous studies. Inpatients received education concerning alcohol and sexuality either with or without an AIDS component. AIDS education and offer of HIV testing were associated with increased requests for HIV testing.     

Correlates of HIV infection among young adult short-term injection drug users

OBJECTIVES: To identify risks associated with HIV infection among young adult short-term injection drug users. METHODS: Current injection drug users, between 18 and 29 years of age, were recruited through street outreach to participate in a cross-sectional survey of HIV prevalence by circumstances of drug injection initiation, HIV-related risk behaviors, and a follow-up to estimate HIV incidence. RESULTS: At enrollment, 33 (14.4%) of 229 participants were HIV-seropositive. Significant bivariate associations with HIV at the time injection drug use was initiated included age less than or equal to 18 years, having receptive anal sex with the person who assisted with initiation, and having two or more 'trainers' before being able to self-inject. Injecting risks positively associated with HIV included cocaine or speedball (heroin and cocaine together) injection versus heroin or amphetamine injection, injecting five or more times per day, daily crack smoking, backloading, sharing needles at peak drug use, and not using a new needle for every injection. Sexual practices associated with HIV included reporting > 100 lifetime sex partners, a history of sexual assault, being gay or bisexual, and trading sex for money or drugs after starting to inject. In a multivariate model, trading anal sex for money or drugs after initiating injection drug use [odds ratio (OR), 14.2; 95% confidence interval (CI) 3.2-62.3], cocaine/speedball injection (OR, 10.3; 95% CI, 2.2-47.9), daily crack smoking (OR, 4.2; 95% CI, 1.7-10.5), and having two or more trainers (OR, 2.6; 95% CI, 1.1 - 5.9) were independently associated with HIV. During 12 months of follow-up, four persons seroconverted for HIV (annual incidence: 2.6%; 95% CI, 1.1 -5.9%) CONCLUSIONS: Among short-term injectors, both sexual and injecting practices were important predictors of HIV infection, indicating that a proportion of HIV infections among young injection drug users can be attributed to sexual transmission. The incidence rate for HIV infection suggests that immediate steps should be taken to prevent new infections among young injection drug users.     

Intravenous drug users and AIDS: risk behaviors

Risk-taking behaviors were studied in this assessment of 345 intravenous drug users from Baltimore, El Paso, and Denver. Over 50% reported injecting drugs daily and 70% shared needles with others, averaging 6.3 partners. In addition, 86% had shared a "cooker" and nearly 50% injected in a "shooting gallery." More than half of the males sampled had two or more sex partners, including 18% with five or more. Females averaged 19 sex partners in the preceding 6 months, with 22% reporting sex with five or more. Two-thirds of the total sample never used a condom, while only 6% always used this form of protection. On the other end of this risk continuum were those subjects who did not share needles or always cleaned their needles with an effective agent, had no sexual relations or always used a condom. Subjects following such practices could be considered low risk if they adopted safe behaviors in other associated areas of their lives. However, in an analysis of total risk, it was found that only 14 subjects (4%) practiced safe needle use and safe sex. Despite these findings, some encouraging results were seen. In an analysis of risk according to location, Baltimore subjects were significantly less at risk according to number of needle-sharing partners, borrowing needles, sharing a "cooker," injection in a "shooting gallery," cleaning needles, use of disinfectants, number of sexual partners, and use of condoms than either their cohorts in El Paso or Denver. Street outreach to modity risk behaviors among IVDUs began in Baltimore approximately 2 years prior to funding in El Paso and Denver. These results suggest that there may be a potential to moderate risk through intervention.     

Sexual, contraceptive, and drug use behaviors of women with HIV and those at high risk for infection: results from the Women's Interagency HIV Study

OBJECTIVE: To document the sexual and contraceptive practices of women with HIV infection or who are at risk for infection. DESIGN: Data on the baseline behaviors of 561 HIV-negative and 2040 HIV-positive women were collected as part of the Women's Interagency HIV Study (WIHS). WIHS is a multisite, longitudinal study following the natural history of HIV infection among women in the United States. METHODS: Each participant contributed an interviewer administered, self-report interview including questions on sexual and contraceptive behavior. RESULTS: Women with HIV were less likely to report heterosexual activity in the previous 6 months (65% HIV-positive, 76% HIV-negative). Among sexually active women, there were no differences in the proportion of those reporting vaginal (97% HIV-positive, 98% HIV-negative) or anal sex (12% HIV-positive, 10% HIV-negative), although women with HIV were less likely to report cunnilingus (41% HIV-positive, 70% HIV-negative) and fellatio (48% HIV-positive, 57% HIV-negative). Of women with HIV, 63% always used condoms during vaginal sex (versus 28% HIV-negative), with lower rates reported during other sexual activities. Crack, cocaine, or injecting drug use, reported by 27% of HIV-positive and 35% of HIV-negative women, was associated with inconsistent condom use, independent of serostatus. HIV-positive women who reported using condoms and another contraception method were less consistent condom users (57% consistent versus 67%). CONCLUSIONS: The prevalence of sexual risk behavior in this sample suggests that, although women with HIV exhibit lower levels of sexual risk behavior than uninfected women, many have not been successfully reached with regard to implementing safer behaviors. These findings have implications for more widespread and effective behavioral intervention efforts.     

北京市吸毒人群艾滋病病病毒感染状况的调查

1998年11月～12月对599名吸毒者进行HIV/AIDS血清学调查,检出HIV阳性者9例,阳性率为1.5%.调查对象中252例(42.1%)采用注射吸毒或吸食、注射交替方式;42例(16.7%)有与他人共用针具史,注射吸毒者HIV阳性率为3.6%.49例(11.1%)承认有婚外性行为,213例(70.5%)在性行为活动中未采取保护措施.本调查结果对于北京市吸毒人群的HIV感染率水平仍属低估.     

HIV risk among women injecting drug users who are in jail

Female offender populations and females in jail include large proportions of injecting drug users (IDUs), who are at high risk of contracting or transmitting HIV. Women IDUs (n = 165) were recruited and interviewed at New York City's central jail facility for women. The study examined these women's patterns of HIV risk behaviors related to drugs and sex and identified behavioral and attitudinal correlates of HIV serostatus. The women typically used both injectable and non-injectable drugs prior to arrest, primarily heroin, cocaine powder, crack, and illicit methadone. Self-reported HIV seropositivity was 43%. Variables correlated with HIV serostatus in the bivariate analysis were: cocaine injection frequency; lifetime injection risk behavior; providing oral sex during male crack use; Hispanic ethnicity; sharing of needles/syringes; sharing of cookers; sharing injection equipment with friends; heroin smoking (negative); injection risk acceptance; peer norms and behavior; lifetime sexual risk behavior; frequency of sex with men; provision of sex for money or drugs; and knowing people with AIDS. The first four variables listed retained statistical significance in a multiple logistic regression analysis. The paper considers the need to tailor AIDS prevention interventions for woman IDUs in jail, including taking into account risk behaviors that occur within frequently reported same-sex partnerships.     

Sexual and Physical Victimization as Predictors of HIV Risk Among Felony Drug Offenders

Injection and other drug use and high-risk sexual behaviors put criminal offenders at increased risk for HIV infection. Studies in other populations, especially females, have found that a history of sexual or physical victimization increases engagement in HIV-risk behaviors, and drug-involved offenders have high rates of such prior victimization. However, there has been little research among male offenders. In a sample of 247 male felony drug offenders in New York City, prior sexual victimization was related to a higher number of sex partners and lower proportion of protected sex acts in the 30 days before arrest. Prior physical abuse was related to cocaine injection, but not heroin injection or high-risk sex behaviors. These results suggest a complex relationship between sexual and physical abuse and HIV risk among male offenders. Assessing for specific prior abuse histories of offenders and providing targeted interventions may be useful for developing more effective primary and secondary HIV prevention services for this high-risk population.     

Assessing risk behaviors and prevalence of sexually transmitted and blood-borne infections among female crack cocaine users inSalvador--Bahia, Brazil.

Crack cocaine use is associated with risky sexual behaviors and sexually transmitted infections (STIs), including HIV. We investigated sociodemographic and behavioral characteristics and infection rates in female crack cocaine users from impoverished communities of Salvador, Bahia, Brazil. A sample of 125 female crack cocaine users was recruited. Overall, the interviewees had low educational level and high rate of unemployment (close to 90%). One-third (37%) reported having traded sex for money or drugs, and 58% reported that they had not used condoms during intercourse in the last 30 days. The prevalence of infections was low: HIV-1.6%; HCV-2.4%; HBV- 0.8%; HTLV I/II-4.0%; and syphilis-4.0%. The combination of dire poverty and high prevalence of risk behaviors turn such populations a preferential target of initiatives aiming to reduce drug-related harm and promote social development. Low infection rates should not be viewed with complacency, but as a window of opportunity to implement prevention initiatives and reduce social marginalization.     

Behavioural changes in intravenous drug users in Geneva: rise and fall of HIV infection, 1980-1989

In the early 1980s, more than 90% of intravenous drug users (IVDUs) shared needles and syringes in Geneva. The prevalence of antibodies to HIV in the sera of outpatient IVDUs increased from 6% in 1981 to 38% in 1983; it was, however, still only 37% in 1988. IVDUs starting methadone maintenance in 1987-1989 had a seroprevalence rate of 22%. In 1989 the percentage of IVDUs exchanging syringes and needles fell to only 5% of seropositive addicts. Only one seroconversion was observed in 1094 patient-months of observation in 1988-1989, which was probably due to sexual contact. The evidence suggests that, in the IDVUs studied, transmission of HIV has diminished since the early 1980s.     

1990～1998年云南省HIV感染者个人档案资料分析

目的对HIV感染者危险行为、临床表现及转归进行分析.方法每年对新发现的感染者进行入户调查和体检,填写个案调查表.结果感染者中88%为吸毒者,其中67%的人经常与他人共用注射器吸毒,28%的女性感染者有卖淫行为,24%的男性感染者有嫖娼行为,感染者与配偶和性伴经常使用安全套的比例为13%;主要临床症状为全身淋巴结肿大、体重下降、发热、咳嗽、皮疹和腹泻;164例(7%)感染者在随后的随访中被诊断为艾滋病病人;456人(19.4%)在随访过程中发现已经死亡.感染者从发现感染到发病的时间最长为10年,最短为1年,平均为5.06年.结论绝大多数感染者通过共用注射器静脉吸毒感染艾滋病,相当一部分感染者同时存在卖淫、嫖娼和性乱行为,安全套使用率低,性传播威胁大,感染者多出现呼吸道、消化道和皮肤症状,从发现感染到发病的平均时间为5.06年.