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Illicit drug use and HIV risk behaviors among young African-Americans.

Dear Editor:

Public health efforts have been directed toward promoting the use of condoms among sexually active individuals. Condoms have been shown to reduce the risk of sexual transmission of a number of diseases (National Institutes of Health, 2002). Despite efforts geared toward reduction of transmission and information disseminated about transmission and risk of disease, high-risk practices, including sex with multiple partners and nonuse of condoms, make sexually transmitted diseases (STDs) a persistent public health problem.

Substance use has been shown to occur with high-risk sexual practices in young people (Flom, Friedman, Kottiri, Neaigus, Curtis, Des Jarlais, Sandoval, & Zenilman, 2001). Drugs and alcohol also may be used deliberately at the time of intercourse to facilitate sex (Taylor & Fulop, 1999). Substances commonly used by people who engage in high-risk sexual activity include marijuana, powder cocaine, crack, heroin, speedball and alcohol (Sanchez, Comerford, Chitwood, Fernandez, & McCoy, 2002). Researchers (Taylor & Fulop, 1999) reported a positive relationship between unprotected sex and substance use. Substance use has also been shown to occur with a history of sex with multiple partners (Taylor & Fulop 1999; Sanchez, et al., 2002). According to von Haeften, Fishbein, Kaspryzk, and Montano (2000), people are more likely to use condoms with casual sex partners than with regular partners. This was shown to be true even in a study in which both condom use and substance use by participants were greater with casual partners than with primary or regular partners (Baker, Morrison, Gilmore, & Schock, 1995). Though the relationship between drug use and HIV-related risks has been well documented in the literature, limited information is available for young African-Americans. The purpose of this study was to examine the association between drug use and HIV risk-related sex behaviors among young African Americans.

Data for this study were collected in a cross-sectional community survey conducted for a drug abuse and HIV intervention study in Birmingham, Alabama, from 2000-2002. Four zip codes were selected based on seven health and criminal justice indicators of risk for HIV, STDs, and substance abuse. The sites for the intercept interviews within each zip code were systematically selected to obtain the greatest number of drug users. Informants, such as neighborhood association leaders, former substance users, and local police, identified drug-trade areas.

For several days prior to surveying, the teams visited the sites and distributed literature about the project and free condoms in order to make the area residents feel more comfortable with their presence. Recruitment was facilitated by approaching individuals and offering them an incentive (a $5 McDonald's gift certificate). The refusal rate was about 15%. Only those who reported that they had used marijuana or cocaine (including crack) during the past six months were recruited for the interview:

Interviews lasted from 15 to 20 minutes. Interviewers asked respondents about their alcohol, marijuana and cocaine (including crack) use in the past 30 days. Respondents also were asked if they had had sex without a condom in the past 30 days with their main sex partner and other sex partners; how many sex partners they had had in the past 30 days; and whether they had used drugs during sex in the past 30 days.

A group of African-American young people (N = 182), between 15 to 24 years of age, was included in the analysis. All subjects reported having used marijuana or cocaine during the past six months. However, based on the self-reported marijuana or cocaine use during the past thirty days, they were classified into one of three groups: (1) any respondent who reported cocaine use was included in the cocaine user group (n = 43); (2) any respondent who reported marijuana use, but not cocaine use, was included in the marijuana user group (n = 72) and; (3) those individuals who reported not using marijuana or cocaine during the past 30 days were included in the ex-drug user group (n = 67). The demographics of the sample showed that there were more females than males (52.2% vs. 47.8%).

To examine the relationship between drug use and sexual behaviors, a series of chi-square tests on drug use and HIV risk behavior was used. The analysis was one on the total sample as well as for males and females separately. Table 1 presents statistics and percentages regarding unprotected sex with main sex partners and other sex partners by drug use groups. For the total sample, marijuana and cocaine users were more likely not to use condoms than ex-drug users with their main sex partners and other sex partners. Compared to marijuana users, cocaine users were more likely not to use condoms than ex-drug users with their main sex partners and other sex partners. Compared to marijuana users, cocaine users exhibited no statistically significant difference in condom use in relation to their main sex partners. Cocaine users were more likely than marijuana users not to use condoms in relation to their other sex partners. Looking at gender separately, there were no drug type differences in condom use among males with their main sex partners. Male cocaine users were more likely not to use condoms in relation to their other sex partners than male marijuana users and ex-drug users. For females, a different pattern was noted. Female marijuana and cocaine users were more likely than ex-drug users not to use condoms in relation to their main sex partners. Among females, there were no statistically significant drug use group differences for using condoms with other sex partners.

Table 2 presents the percentage that reported having multiple sex partners during the past 30 days. The multiple sex partners item was derived from the survey question "how many different sex partners did you have during the past 30 days?" Those who reported having two or more sex partners were defined as the multiple sex partners group. For the total sample and for males, cocaine and ex-drug users were more likely to report multiple sex partners than marijuana users. The percentage of multiple sex partners did not differ by drug use group for females.

Table 3 presents percentages on drug use during sex with main and other sex partners. For this analysis, the ex-drug use group was not included. Results showed that for the total sample, there was no statistically significant difference between marijuana and cocaine users in their reported drug use during sex with their main sex partners, p > .05. No gender effects were found. There was a statistically significant difference between marijuana and cocaine users in their reported drug use during sex with their other sex partners, p < .05. More cocaine users (51%) reported drug use during sex with their other sex partners than marijuana users (36%). The significant difference appeared to reflect behavior only among females. The number of female cocaine users (52%) who reported using drugs during sex with their other sex partners was more than double that of the female marijuana users (25%), p < .05.

The data from the study suggested that the participants who were engaged in illicit drug use, particularly cocaine, were more likely to engage in high-risk sexual behavior than current non-drug users. This was especially true for the relationship between drug use and unprotected sex and also in the use of drugs during sex. The occurrence of such relationships and patterns of behavior may be explained by the likelihood that multiple health-endangering practices have a tendency to occur in the same individuals. Secondly, illicit substances may be used at the time of sex to reduce inhibition or to facilitate or enhance sexual practices and experiences. In turn, the intoxication or euphoria that may result from substance use could cloud a person's judgment and increase the likelihood that a person would engage in unsafe sexual practices such as nonuse of condoms (Taylor & Fulop, 1999). These findings are consistent with those obtained in some previous studies (Flom et al., 2001). In other studies, different types of relationships have been reported: in one study, condom use with casual sex partners was increased compared to regular sex partners even though substance use was more likely during sex with casual partners (Baker et al., 1995). It has also been reported by some study participants that while habitual use of cocaine was associated with increased sexual activity, sexual desire and the ability to engage in sex were diminished after smoking crack (Weatherby, Shultz, Chitwood, McCoy, McCoy, Ludwig, & Edlin, 1992).

In addition to the general findings, differences among drug use categories were identified. First, there were differences in the relationships for each of the various types of drugs used to sexual behavior. Marijuana use was found to have a weaker relationship with HIV risk behaviors than cocaine use. Unprotected sex with other sex partners appeared to occur mostly among cocaine users while unprotected sex with main sex partners appeared to occur among cocaine users and marijuana users. The absence of a negative effect of marijuana use on condom use with casual sex partners might have occurred due to the likelihood that condoms are more likely to be used with casual sex partners than with the primary sex partner in general (Baker et al., 1995). The differences between the drug groups were also evident in the risk for engaging in sex with multiple partners.

Among current drug users, the cocaine users appeared to have a higher chance than marijuana users of having multiple sex partners. It is surprising that slightly over forty percent of ex-drug users also reported having multiple sex partners. This finding suggests that all drug users, whether they were current or ex-drug users, were at risk for spreading sexually transmitted diseases. The findings were somewhat conflicting with the previous findings which indicated an increasing pattern of risky sexual practices from those who did not use drugs, to marijuana users, to non-injecting cocaine users (Flom et al., 2001). Future studies will be needed to further investigate the possible differences in roles played by different drugs in influencing sexual practices. Why there were as many ex-drug users as cocaine users who admitted to multiple sex partners is unclear. It may be due to the influence of other social or economic factors that were not controlled for in this study. A search of literature has provided no information to offer any explanations.

Significant gender differences were found in the relationships between the different drugs and sexual practices. First, female participants who used drugs had a greater tendency to report non-condom use with their primary or main sex partners while male participants were more likely to report non-condom use with their other sex partners. Secondly, while the male marijuana users were generally found to be less likely than crack users and ex-drug users to engage in sex with multiple partners, this relationship was not found among the female participants. The data also serve to restate the importance of additional factors that may be responsible for gender differences in sexual practices and condom use. Our findings support the literature on the gender differences in sexual behavior and its relationship to drug use (LaBrie, Schiffman, & Earleywine, 2002). However, our findings do not support the results that found young men are more likely to use condoms than young women (Santelli, Lindberg, Abma, McNeely, & Resnick, 2000).

The findings support the need for early interventions. An early gender-tailored intervention to (1) forestall the onset of drug use, (2) delay the onset of sexual intercourse, and (3) discourage unsafe sexual practices, should have an effect in reducing the prevalence of drug dependence and sexually transmitted diseases. The need for early interventions are in line with reports that early involvement in illicit substance use increases both the likelihood of high-risk sexual behavior and the risk of earlier initiation of sexual activity (Fergusson & Lynskey, 1996).
Table 1. Percentages and significance test of unprotected sex
with main and other sex partners among drug use types

With main sex partner Total sample * Male Female *
Ex-drug users 56.52 71.43 44.00
Marijuana 74.14 65.52 82.76
Cocaine 79.17 100.00 66.67

With other sex partner Total sample * Male * Female
Ex-drug users 39.47 37.50 40.91
Marijuana 48.78 42.31 60.00
Cocaine 71.88 78.57 66.70

* p < .05 for the chi-square test

Table 2. Percentages and significance test of multiple sex partners
among drug use types

 Total sample ** Male * Female

Ex-drug users 40.30 48.48 32.35
Marijuana 23.61 27.78 19.44
Cocaine 37.21 44.44 32.00

* p < .05 for the chi-square test. ** p < .01 for the chi-square test.

Table 3. Percentages and significance test of drug use during sex among
drug use types

With main sex partner Total sample Male Female

Marijuana 36.11 36.11 36.11
Cocaine 27.91 16.67 36.00
With other sex partner Total sample * Male Female *
Marijuana 36.11 47.22 25.00
Cocaine 51.16 50.00 52.00

* p < .05 for the chi-square test


References

Baker, S. A., Morrison, D. M., Gilmore, M. B., & Schock, M. D. (1995). Sexual behaviors, substance use, and condom use in a sexually transmitted disease clinic sample. Journal of Sex Research, 32, 37-44.

Fergusson, D. M. & Lynskey, M. T. (1966). Alcohol misuse and adolescent sexual behaviors and risk taking. Pediatrics, 98, 91-96.

Flom, P. L., Friedman, S. R. Kottiri, B. J., Neaigus, A., Curtis, R., Des Jarlais, D. C., Sandoval, M., & Zenilman, J. M. (2001). Stigmatized drug use, sexual partner concurrency, and other sexual risk network and behavior characteristics of 18 to 24 year old youth in a high-risk neighborhood. Sexuality Transmitted Diseases, 28, 598-607.

von Haeften, I., Fishbein, M., Kaspryzk, D., & Montano, D. (2000). Acting on one's intentions: Variations in condom use intentions and behaviors as a function of type of partner, gender, ethnicity and risk. Psychology, Health & Medicine, 5, 163-171.

LaBrie, J. W., Schiffman, J., & Earleywine, M. (2002). Expectancies specific to condom use mediate the alcohol and sexual risk relationship. Journal of Sex Research, 39, 145-152.

National Institutes of Health (2002). Workshop summary: Scientific evidence on condom effectiveness for sexually transmitted disease (STD) prevention. Retrieved November 1, 2002, from http:// www.niaid.nih.gov/dmid/stds/condomreport.pdf.

Sanchez, J., Comerford, M., Chitwood, D. D., Fernandez, M. I., & McCoy, C. B. (2002). High-risk sexual behaviors among heroin sniffers who have no history of injection drug use: Implications for HIV risk reduction. AIDS Care, 14, 391-398.

Santelli, J. S., Lindberg, L. D., Abma, J., McNeely, C. S., & Resnick, M. (2000). Adolescent sexual behavior: Estimates and trends from four nationally representative surveys. Family Planning Perspectives, 32, 156-165.

Taylor, J., & Fulop, N. (1999). Drink, illicit drugs and unsafe sex in women. Addiction, 94, 1209-1218.

Min Qi Wang, Ph.D., The University of Maryland Joseph Schumacher, Ph.D., University of Alabama at Birmingham Sacia Dear, M.A., University of Alabama at Birmingham Damilola Ogunlesi, MB.BS, The University of Maryland Foster Cook, M.A., University of Alabama at Birmingham

Weatherby, N. L., Shultz, J. M., Chitwood, D. D., McCoy, H. V., McCoy, C. B., Ludwig, D. D., & Edlin, B. R. (1992). Crack cocaine use and sexual activity in Miami, Florida. Journal of Psychoactive Drugs, 24, 373-380.
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Title Annotation:Letter To The Editor
Author:Cook, Foster
Publication:Journal of Alcohol & Drug Education
Geographic Code:1USA
Date:Dec 1, 2004
Words:2504
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