Perceived importance of condom use among African Americans using drugs.

Abstract: This study examined the relationship between the perceived importance of using condoms and the condom use among African American users of drugs (marijuana and cocaine) in a street outreach study. Despite the existence of scientific evidence that consistent condom use is a key factor in reducing heterosexual transmission of HIV, the cognitive factors that govern condom use, especially in users of non-injected drugs (crack and marijuana) is not very clear. As such, this study investigated perceived importance of condom use, the type of sex partners, drug use type, and gender of a group of African American users of drugs in a high-risk street outreach study. The key points discussed are: 1) major perceived importance of condom use associated with the actual condom use 2) condom use in main and other partners, 3) gender differences, and 4) differences in drug type related to condom use.

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Human Immunodeficiency Virus (HIV) infection and Acquired Immunodeficiency Syndrome (AIDS) continue to ravage communities of color, and are more closely associated with communities with low social economic levels. It is generally accepted that consistent condom use can prevent the transmission of HIV and sexually transmitted diseases (STD) and is often the key component of HIV prevention efforts. (Davis & Weller, 1999; Friedman, 2001). Consequently, HIV and AIDS prevention programs must target populations at high risk and promote the use of condoms. There are many reasons why people use, or do not use condoms during sex with their partners. In order to effectively promote consistent condom use, it is imperative to identify factors that influence condom use.

COGNITIVE MODELS

Literature has indicated that when people were afraid of being infected with HIV and perceived that condom use could reduce the threat of HIV, STDs and pregnancy, they were more likely to use condoms (Mickler, 1993; Oswalt & Matsen, 1995). In addition, it was also found that a high sense of self-efficacy and self-control, the perceived susceptibility to HIV infection (Goldman, 1993), and high moral reasoning skills (Hubbs-Tait & Garmon, 1995) were associated with consistent condom use. It appears that most of these psychological findings were obtained from non-drug use college populations. These cognitive models emphasize individual-based variables such as knowledge, attitudes, health beliefs, and behavioral intentions (Amaro, 1995; Kelly et al., 1992; Peterson et al., 1991), and appear to de-emphasize the salient dement of sexuality; its non-rational, emotional, counterpart i.e., the relationships between sex partners. It is important to link the perceived importance of condom use with actual condom use in order to identify the most relevant cognitive factors that could be incorporated in behavioral interventions.

PRIMARY AND OTHER SEX PARTNERS

The nature of the sexual relationship has an impact on the sexual practices. Condom use that occurs within steady, ongoing relationships has different implications for prevention than condom use in casual sexual encounters. A consistent finding in both population-based surveys (Kalichman, 1999) and studies of high-risk groups (Kalichman, 1997) has been that condom use is much lower with steady or regular partners than with other types of partners (Carball-Dieguez & Dolezal, 1996). A study by Anderson, Wilson, and Doll (1999) found that 62% of the adults in their study reported using a condom during an intercourse, which did not involve their primary partner. This was in sharp contrast to the 19% that reported using a condom during the last intercourse with their primary partner. Condom use behavioral and cognitive factors should be investigated an individual's main as well as with other sex partners.

TYPE OF DRUG USE

Sexual behaviors are related to individual characteristics such as drug use, which is directly and indirectly linked with increased transmission of HIV. Users of crack cocaine, heroin, and marijuana are more likely to engage in high risk sexual behaviors (Flom PL, Friedman SR, Kottiri BJ, 2001). Drug use and its associated behaviors may reduce the probability of condom use (Friedman, Flom, & Kottiri, 2002). They reported higher incidence of unprotected sex, among other high-risk behaviors. It is important to examine drug and types of drug use on the perception of condom use and reported condom use when conceiving HIV prevention efforts.

GENDER

Between 1985 and 1999, the ratio of HIV infection among men and women showed a reverse trend. Since 1985, the proportion of all AIDS cases reported among adult and adolescent women has increased from 7% in 1985 to 25% in 1999, which is more than three times the proportion seen in 1985 (CDC). More women were being infected than men. This indicated an increase in heterosexual transmission. Unprotected sex is one of the highest-ranking risk factors among these women before contracting HIV (Wilson, Massad, & Riester, 1999). At-risk women are involved in unprotected sex during prostitution for drugs and submissive or abusive relationships with men. Gender, thus, is another important factor in understanding condom use as HIV risk prevention.

HIGH RISK COMMUNITY

In neighborhoods and populations where HIV and STDs are widespread, condom use is particularly important. Studies of local area variation (typically based on census block-groups or census tracts) have found that the HIV/AIDS epidemic has been concentrated in areas with a high proportion of racial/ethnic minorities and the poor (Fife & Mode et al., 1992; Hu et al., 1994; Krieger et al., 2000; Morse et al., 1991; Simon et al., 1995). Approximately half of current HIV incidence in this country occurs among drug injectors (Holmberg, 1996), largely among those in impoverished racial/ethnic minority neighborhoods. Heterosexual AIDS cases have been increasing in the metropolitan cities, and are concentrated in a few neighborhoods that are also the loci for HIV/AIDS among injection drug users (IDU) (Fordyce et al., 1999). Thus, in many ways the problem of preventing heterosexual transmission of HIV requires heavy focus on neighborhoods where drug use and HIV are both prevalent.

RESEARCH CONTEXT AND PURPOSE

Although there have been a few studies regarding non-injection drug use and HIV risks, there is limited data on African American users of drugs. More empirical information is needed in this area. As a result, the Center for Substance Abuse Treatment funded a multi-site street outreach project. This study, funded as one of these sites, examined the relationship between the perceived importance of using condoms and the condom use among African American users of drugs (marijuana and cocaine) in a street outreach study. Despite the existence of scientific evidence that consistent condom use is a key factor in reducing heterosexual transmission of HIV, the cognitive factors that govern condom use, especially in non-injected drug (crack, marijuana) users is not very clear. As such, this study investigated perceived importance of condom use, the type of sex partners, drug use type, and gender of a group of African American users of drugs in a high-risk street outreach study. These factors have been cited in the literature (Davis & Weller, 1999).

METHODOLOGY

SURVEY SITE SELECTION

Data for this study were collected in a cross-sectional community survey conducted for a drug abuse and HIV prevention study in Birmingham, AL. Four zip codes were selected based on seven health and criminal justice indicators of risk for HIV, STDs, and substance abuse. These indicators included Drug Use Forecasting data, Healthy Start data, and STD and HIV prevalence data, which were used to identify comparable high-risk zip codes. 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 users of substances, and local police, helped identify drug-trade areas.

SAMPLING PROCEDURES

Interviewers talked to all the potential participants. Only those who indicated that they used illicit drugs (marijuana or crack) during the past 6 months were interviewed. Participants had to be adults, fifteen years or older who were traveling on foot, unarmed, and appeared to be indigenous to the area.

To determine the probability sample needed per zip code, we first estimated the size of the target population of users of drugs by taking the Alabama drug use prevalence rate (11%) and applying it to each zip code. This calculation provided an estimate of 8,200 users of drugs in these sites. This was most likely a conservative estimate because it was based on state prevalence rates, while the prevalence rates within the target zip codes were believed to be higher. Next, we determined the minimum probability sample size needed for a 95% confidence interval and 3% error rate which yielded a target sample of 401 users of drugs (Wang, Fitzhugh, & Westerfield, 1995).

The completed interviews achieved this statistical power with a total of 1,630 completed interviews. For the purpose of this study only individuals who used marijuana and crack (cocaine) during the past three months were included (n=718), exceeding the required sample size of 401 with a 95% confidence interval and a 3% error rate.

In order to make the sample more representative of the people residing within each zip code area, individuals were interviewed at selected interview sites that covered all zip codes. Interviewers were given a set number of people to talk to before moving on to the next site. One question, included in the survey, asked if the respondent lived in the zip code area. The number of people per zip code was divided by the number of sites to give a per-site quota.

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 estimated refusal rate was about 15%.

SURVEY INSTRUMENT AND INTERVIEWS

Street interviews about drug use, sex, condom use, and reasons for condom use were conducted almost daily from year 2000 to 2002. Interviews lasted from 15 to 20 minutes initially, but were slightly shorter after the team gained experience. Interviewers asked respondents about their alcohol, marijuana and cocaine (including crack) use in the past 30 days. Respondents were also asked if they had sex without a condom in the past 30 days with their main and/or other sex partners. Respondents were also asked about the reasons for condom use with their partners. There were items indicating reasons for condom use and respondents rated the importance of each statement for their main partner and other partners. Consequently, for each statement, there were two questions. For example, if the first statement was: "You think your partner is safe", then the two questions were: "How important is this for using condoms with your main partner?" and "How important is this for using condoms with your other partner?" The response categories were on a 5-point Likert scale ranging from "Not Important" (score 1) to "Very Important" (score 5). There were a total of 15 statements. The complete list of these statements is in the Appendix. The alpha reliability coefficients of reasons for condom use were .96 for main partners, and .95 for other partners.

The survey was pilot tested with twenty participants in a drug treatment program. Based on the pilot test results, items that were difficult to understand, yielded ambiguous data, or yielded data that were not useful were revised or deleted. The survey was field tested in each of the targeted areas in conjunction with intensive interviewer training.

DATA ANALYSIS

A univariate logistic regression analysis was conducted to examine the relationships between predictor variables (reasons of importance for condom use) and reported condom use, which was the dependent variable. Odds ratios (OR) were obtained to measure the associations between each reason for condom use variable and condom use. The analysis was performed separately by male and female samples and by drug use type (marijuana, and cocaine).

RESULTS

Table 1 presents sample characteristics. The demographics of the sample showed that the prevalence of male and female samples were almost identical (49.3% vs. 50.7%). The majority of the sample was in the 40 or under age categories, accounting for approximately 83% of the sample. Less than one-third of the sample reported that they were unemployed (29.5%). About 90% either lived with a partner or lived alone. Slightly over half of the samples finished high school. About 28.1% of the sample did not complete high school, 52.1% graduated from high school, and 19.9% reported having some college or higher education.

DRUG AND CONDOM USE

There were 56.3% primary marijuana users and 43.7% primary crack (cocaine) users by self-report. About 84.9% of the sample reported not using condoms with their main sex partners, and 61.3% reported not using condoms with their other sex partners in the past 30 days. When condom use was examined by drug type and gender, a gender difference was observed. Male primary crack (cocaine) users were more likely than their female counterparts not to use condoms with their main sex partners (88.79% vs 83.46%), and with their other sex partners (67.37% vs 61.17%). However, female primary marijuana users were more likely than their male counterparts not to use condoms with their main sex partners (89.47% vs 79.35%), and with their other sex partners (62.92% vs 54.87%).

IMPORTANCE OF CONDOM USE AND ACTUAL USE: MARIJUANA

To examine the relationship between the self-reported importance of condom use and the actual condom use, a series of univariate logistic regression analyses were performed breaking the analyses down by gender and partner variables. The analysis was done on the total sample as well as for males and females separately. Table 2 presents the results for users of marijuana. Data showed for male users of marijuana, only one variable turned out to be significant for main sex partner. Male marijuana users who indicated that "You would feel safer from disease using condom" as important were almost three times as likely to use condoms with their main sex partners (OR=2.97). However, there were six significant predictor variables of condom use for other sex partners.

Male marijuana users who indicated important on the following: "You think your partner is safe", "You would feel safer from pregnancy using a condom," "You would feel safer from disease using a condom," "Your partner would feel safer if you used one," "You would feel more responsible using a condom," and "Condoms protect my sex partner as well as myself," were more. likely to have used condoms. The range and the magnitude of odds ratios of these significant variables (2.16 to 3.92) indicate that male marijuana users were two to four times more likely to use condoms when they considered these factors important than male marijuana users who did not consider these factors as important.

For female marijuana users, the pattern appeared somewhere similar to the male marijuana users. Male and female users of marijuana who indicated that "You would feel safer from disease using a condom" as being important were significantly more likely to use condoms with their main sex partners. Female users of marijuana indicated that "You would feel more responsible using a condom" were 7.38 times more likely to use a condom.

Out of the six variables that were significant for male marijuana users for their other sex partners, five turned out to be significant for females. Female marijuana users who indicated importance on the following: "You think your partner is safe", "You would feel safer from pregnancy using a condom," "You would feel safer from disease using a condom," "Your partner would feel safer if you used one," and "Condoms protect my sex partner as well as myself," were more likely to have used condoms. The magnitude of the odds ratios of these significant variables (2.75 to 3.75) indicated that female marijuana users were at least twice as more likely to use condoms when they considered these factors important than female marijuana users who did not consider these factors important.

IMPORTANCE OF CONDOM USE AND ACTUAL USE: COCAINE

Table 3 presents the results for users of crack (cocaine). Data showed for males, one predictor variable was significant for main sex partner. Male users of crack (cocaine) who indicated that "Your partner would feel safer if you used one" as important were significantly more likely to use condoms with their main sex partners (OR=4.22) than male users of crack (cocaine) who did not consider this factor as important. In contrast to the main sex partners, there were eight significant predictor variables of condom use for other sex partners. In addition to the six significant variables found for male users of marijuana (see Table 2), two additional variables were significant for male users of crack (cocaine) and they were: "It would be too much trouble for you to get a condom," and "My partner would think I had been fooling around." The range of odds ratios of these significant variables was from 2.47 to 6.54, suggesting a strong relationship between the condom use and the perceived importance of condom use for male users of crack (cocaine).

For female crack (cocaine) users, the pattern appeared somewhat different from male users of crack (cocaine). Female users of crack (cocaine) who indicated that "Your partner would feel safer if you used one" (OR=2.81) and "You would feel more responsible using a condom" (OR=3.71) as being important were significantly more likely to use condoms with their main sex partners. Compared to their male counterparts, females had three versus five significant predictor variables of condom use for other sex partners. Female users of crack (cocaine) who indicated importance on the following: "You would feel safer from disease using condom" (OR=6.15), "You would feel more responsible using a condom" (OR=7.74) and "Condoms protect my sex partner as well as myself" (OR=2.69) were more likely to use condoms.

DISCUSSION

The various psychosocial factors that influence condom use can be of great significance in the intervention strategies for reducing HIV transmission. Although the relationship between drug use and HIV risks has been studied in detail, there are a limited number of studies that have investigated the perceived importance of condom use and consistent condom use among African American drug users. This street outreach study attempts to provide additional empirical data to this field. The key points that deserve special attention are: 1) major perceived importance of condom use associated with the actual condom use 2) condom use in main and other partners, 3) gender differences, and 4) differences in drug type related to condom use.

PERCEIVED IMPORTANCE

Our literature review has revealed the following key points regarding the perceived importance of condom use. Consistent condom use is more likely to be seen when an individual was aware of ones positive HIV serostatus (Marlowe, 1998), was in short-term relationships (Kalichman, 1999) or less stable relationships and serodiscordant relations, where one partner is positive and the other is not (Kalichman, 1997). The results of our study indicate that the perceived importance of condom use depended on factors such as a feeling of safety from disease transmission for both self as well as for the partner, freedom from contraceptive issues, and a sense of responsibility for protecting one self as well as the partner. As the perceived importance of consistent condom use increased, the actual use increased.

MAIN AND OTHER SEX PARTNERS

The nature of the sexual relationships, as discussed previously, has an impact on sexual practices. Not only is condom use less prevalent in the relationships with main partners, but also the reasons for condom use are significantly different. Condoms, generally perceived primarily for contraception and secondarily for disease prevention, were often replaced by oral contraceptives once a relationship became established, and once partners learn to trust one another, their perceived risk for disease transmission decreases. People in monogamous relationships were also reported to use this as a reason not to use condoms (Critelli, 1998). However, such monogamous relationships are becoming short term as well as more rare with increasing use of drugs and alcohol (Wang, et al, 2000).

These findings are substantiated by the results of the present study, which comprised of 56.3% primary marijuana users and 43.7% primary crack (cocaine) users in the study sample. Of these, about 84.9% reported not using condoms with their main sex partners, and 61.3% reported not using condoms with their other sex partners. This high percentage of people who are not using condoms with sex partners can help explain the increase in heterosexual transmission of HIV. The percentage of persons not using condoms with other sex partners as compared to main partners is particularly disturbing despite the twenty percent difference. Sex with other partners is likely to be more risky due to the unknown nature of the partner's history and present sexual or drug use behaviors. Sex with other partners may be isolated and related to prostitution or trading sex and drugs. Condom use during these sexual relations may be a lower priority to obtaining money or drugs to fulfill a craving or relieve a withdrawal syndrome.

The findings of this study, however, suggest that sample participants attribute many more reasons of importance for using condoms for sexual relations with other partners (22 significant odds ratios) as compared to main partners (6 significant odds ratios). Prevention efforts designed to transfer the perceived importance of condom use into condom use behaviors will likely reduce HIV risk among those engaged in risky sexual behavior with other partners.

GENDER

In heterosexual relationships, men have a significant impact on the drug use outcomes and sexual practices of women. Women who exchange sex for drugs are most likely to be in a monogamous relationship (NIH guide, 1996). Women, also seem to be influenced to a great deal by the social empowerment of primary partners (Friedman, 2002). Using sex to obtain drugs for women, as compared to using cash or merchandise for men, place women at increased HIV risk.

The results of the present study suggest there may be an interaction between gender and drug type on the amount of significant predictor variables of condom use. Specifically, males and females did not differ in the number of predictor variables of importance of condom use unless drugs are compared (males had 16 significant odds ratios and females had 12). For marijuana, both males and females had 7 significant predictor variables and for cocaine, males had 9 and females had 5 significant odds ratios predicting reported condom use. The implication might be that females have fewer choices in sexual relations, for example, in submissive or abusive relationships or when they trade sex or money, though not investigated in this study.

DRUG USE

In a prior study by the investigators (Wang et al., 2000), the percentage of having multiple sexual partners steeply increased for non-users of alcohol to users of alcohol, marijuana users and finally cocaine users. Men were reported to have more sexual partners than women in all strata. Cocaine users were also less likely to use condoms, and such condom use was lower for primary sexual partners than for the other partners. This pattern of non-use of condoms by cocaine users was found to be slightly higher for females. Use of drugs during sex was also higher for other sexual partners rather than the primary sexual partners.

Since drug use influences so many of the psychosocial aspects that in turn influence condom use this should be extensively studied. The influence of the drug seems to vary with the type of drug used. Injection drug users were previously considered to be in the highest risk category. Now it is estimated that users of non-injected drugs may also be at high risk because their social, sexual or drug network may include users of injection drugs or users of crack cocaine with higher HIV prevalence (Friedman, 2002). Users of cocaine are not only more likely than non-users of cocaine to use sex in exchange for money or drugs, but such persons are also less likely to report condom use (Marlowe, 1998).

Our results add more evidence to the above-mentioned factors, especially the variables that seem to be important in dictating consistent condom use. Safety from diseases seems to be of more importance to both marijuana and cocaine male users. Females gave more importance to the issues of safety and responsibility whereas for male drug users wearing condoms also seemed to be a way of gaining the trust of their partners. The results of our study also provided further evidence in establishing the drug hierarchy because cocaine users ranked the highest among non-users of condoms.

IMPLICATIONS

The results have proven to a certain measure that unprotected sex is higher in users of drugs, especially of cocaine, and to a lesser extent marijuana. These tares are also higher in women, who in theory have not as much control over condom use, especially in commercial sex. Studies have proved that education and increased awareness may improve compliance with condom use in adolescents, but such results are yet to be established in adult populations. The current incidence rates indicate a dangerously high rate of increase in heterosexual transmission. Although it is generally known that consistent and accurate use of condoms decreases the risk of contracting sexually transmitted diseases and HIV, most health care providers and educators are still struggling with the barriers that prevent high risk populations from obtaining and using condoms (Marlowe, 1998). Therefore, there is a need to understand how these various psychosocial factors can be inculcated into intervention strategies in order to increase the effectiveness of these programs in reducing HIV transmission.

Future studies should also focus on the feelings of safety or complacency in monogamous long-term relationships that endorse unprotected sex. This should be the focus of future change. In addition, since condom use is influenced by a spectrum of behavioral factors, the most important of which is drug use, the populations, which are receiving therapy or rehabilitation for drug use, should be targeted for such programs.

Users of cocaine ranked the highest among nonusers of condoms indicating further investigation into the effect of cocaine on the behavior and thinking process under the influence of cocaine. If these biochemical mechanisms are deciphered, then there may be a potential for a neurotherapeutic cure. Until such time, it can be safely stated that increased perceptions of the safety of consistent condom use should be the crux of nil HIV intervention strategies.

Appendix. Questionnaire for Self-Reported Importance of Condom Use.

1. You think your partner is safe.

2. You would feel safer from pregnancy using a condom

3. You would feel safer from disease using condom

4. It would make sex feel unnatural

5. Your partner would feel safer if you used one

6. You don't want to spoil the moment

7. You would feel more responsible using a condom

8. Condoms cost too much money

9. Condoms protect my sex partner as well as myself

10. It would be too much trouble for you to get a condom

11. It would be too much trouble for you to use a condom

12. My partner would think I had been fooling around

13. Condoms are easily available

14. I would have to rely on my partner's cooperation.

15. Your partner would be angry if you use a condom

For each statement, there were two questions for respondents:

How important is this for using condoms with your main partner?

How important is this for using condoms with your other partner?

Table 1. Frequencies and percentages of sample characteristic

                                                Frequency    Percentage
Gender
  Male                                             354         49.30
  Female                                           364         50.70
Age
  <=29295                                           41.43
  30-40                                            297         41.71
  40+                                              120         16.85
Employed
  Yes                                              485         70.49
  No                                               203         29.51
Marital Status
  Live alone                                       338         48.3
  Married                                          65           9.29
  live w partner                                   297         42.43
Education
  <12 Grade                                        198         28.09
  High School                                      367         52.06
  Some College/College Grad                        140
Drug Use
  Marijuana                                        401         56.32
  Crack (cocaine)                                  311         43.68
Consistent condom use with main sex partner
  Yes                                              90          15.13
  No                                               505         84.87
Consistent condom use with other sex partner
  Yes                                              155         38.75
  No                                               245         61.25

Table 2. Odds Ratios of Consistent Condom Use and Reported
Importance for Marijuana Use

                        MALE                  FEMALE

Self-reported     Main       Other      Main       Other
Reasons          Partner    Partner    Partner    Partner

     Q1          1.22       2.28 *     1.96       3.75 *
     Q2          1.32       2.39 *     1.5        2.97 *
     Q3          2.97 *     2.74 *     3.75 *     3.00 *
     Q4          0.64       0.92       1.43       1.16
     Q5          2.55       2.35 *     3.58       2.96 *
     Q6          0.69       0.9        1.2        1.81
     Q7          2.41       3.92 *     7.38 *     2.21
     Q8          0.78       0.99       0.7        1.79
     Q9          1.93       2.16 *     3.36       2.75 *
     Q10         0.89       0.89       1.13       1.35
     Q11         0.94       1.06       1.26       1.73
     Q12         0.71       1.1        0.63       1.28
     Q13         0.95       1.21       1.15       2.23
     Q14         0.74       0.78       0.94       1.96
     Q15         0.71       1.04       1.3        1.3

* significant at p < .05 level.

Table 2. Odds Ratios of Consistent Condom Use and Reported
Importance for Crack (Cocaine) Use

                        MALE                  FEMALE

Self-reported     Main       Other      Main       Other
Reasons          Partner    Partner    Partner    Partner

     Q1          1.22       3.94 *     1.55       1.63
     Q2          2.24       5.84 *     1.65       2.18
     Q3          3.62       5.87 *     1.75       6.15 *
     Q4          2.44       1.61       1.41       0.84
     Q5          4.22 *     4.13 *     2.81 *     1.35
     Q6          1.29       1.98       0.72       0.8
     Q7          1.72       6.54 *     3.78 *     7.74 *
     Q8          1.63       1.89       1.14       1.15
     Q9          1.72       4.02 *     2.43       2.69 *
     Q10         1.27       2.47 *     1.65       1.52
     Q11         1.31       1.57       1.4        1.33
     Q12         0.66       2.53 *     1.53       1.05
     Q13         1.88       1.71       2.16       1.67
     Q14         1.06       2.26       2.43       1.42
     Q15         0.59       2.21       1.31       0.94

* significant at p < .05 level.

REFERENCES

Amaro, J. (1995). Love, sex, and power, considering women's realities in HIV prevention. American Psychologist, 50, 437-447.

Anderson J. E., Wilson R, & Doll T (1999). Condom use and HIV risk behaviors among U.S. adults: Data from a National Survey. Family Planning Perspectives, 31(1), 24-29.

Carball-Dieguez, A, & Dolezal, C. (1996). HIV risk behavior and obstacles to condom use Puerto Rican men in New York City who have sex with men. American Journal of Public Health, 86, 1619-1622.

Critelli, JW, Suire DM. (1998). Obstacles to condom use: The combination of other forms of birth control and short term monogamy. Journal of American College Health, 46(5), 215-219.

Davis, K. R., & Waller S. C, (1999). The effectiveness of Condoms in Reducing Heterosexual Transmission of HIV. Family Planning Perspectives, 31(6), 272-280.

National Institutes of Health Guide (1996). Drug Use, Sexual Risk Behaviors, and HIV in Men. National Institutes of Health Guide, 25(32), pp 1-9.

Fife D., & Mode C. (1992). AIDS incidence and income. Journal of Acquired Immune Deficiency Syndromes, 5, 1105-1110.

Flom, P. L., Friedman, S. R., & Kottiri B. J. (2001). Stigmatized drug use, sexual partner concurrency, and other sex risk network and behavior characteristics of 18 to 24 year old youth in a high risk neighborhood. Sexually Transmitted Diseases, 28(10), 598-607.

Fordyce E.J., Shum R., Singh TP & Forlenza S. (1999). Economic and Geographic diversity in AIDS incidence among HIV exposure groups in New York City: 1983 to 1995. AIDS and Public Policy, 13, 103-114.

Friedman SR, Flom PL, & Kottiri BJ (2002). Consistent condom use among drug-using youth in a high HIV-risk neighbourhood, AIDS Care, 14(4), 493-507.

Friedman, S. R., (2001). Consistent condom use in the heterosexual relationships of young adults who live in a high-HIV-risk neighborhood and do not use "hard drugs." AIDS Care, 13(3), 285-296.

Goldman J. A., (1993). Self-perception variables that mediate AIDS preventive behavior in college students. Health Psychology, 12(6), 489-498.

HIV/AIDS Among US Women: Minority and Young Women at Continuing Risk, Divisions of HIV/AIDS Prevention, Centers for Disease Control, 2000. http://www.cdc.gov/hiv/pubs/facts/women.htm

Holmberg SD. (1996). The estimated prevalence and incidence of HIV in 96 large US metropolitan areas. American Journal of Public Health, 86, 642-654.

Hu DJ, Frey R, Costa SJ, Massey J, Ryan J, Fleming PL, D'errico S, Ward JW, & Buehler J, (1994). Geographical AIDS rates and sociodemographic variables in the Newark, New Jersey, metropolitan area. AIDS and Public Policy, 9, 20-25.

Hubbs-Tait L, Garmon LC (1995). The relationship of moral reasoning and AIDS knowledge to risky behavior. Adolescence, 30(119), 549-562.

Kalichman SC (1999). Psychological and social Correlates of High-risk Sexual Behavior among Men and Women Living with HIV/AIDS. AIDS Care, 11(4), 415-428.

Kalichman, S. C. (1999). Psychological and social Correlates of High-risk Sexual Behavior among Men and Women Living with HIV/AIDS. AIDS Care, 11(4), 415-128.

Kalichman SC, (1997). Sexual Relationships, Sexual Behavior, and HIV Infection: HIV-Seropositive Gay and Bisexual Men Seeking Prevention Services. Professional Psychology: Research and Practice. 28(4), 355-360.

Kelly J, Murphy D, Roffman R, et al, (1992). Acquired immunodeficiency syndrome/human immunodeficiency virus risk behavior among gay men in small cities: findings of a 16-city national sample. Archives of Internal Medicine, 152, 2293-2297.

Marlowe DB, & Carrigan DR (1998). Counselor prompts to increase condom taking during treatment for cocaine dependence. Behavior Modification, 22(1), 29-44.

Mickler S E (1993). Perceptions of vulnerability: Impact on MDS preventive behavior among college adolescents. AIDS Education and Prevention, 5(1), 43-53.

Morse DL, Lessner L, Medvesky MG, Glebatis DM, & Novick LF (1991). Geographic distribution of newborn HIV seroprevalence in relation to four sociodemographic variables. American Journal of Public Health, 81, S25-S29.

Oswalt R, & Matsen K, (1995). Sex, AIDS and the use of condoms: A survey of compliance in college students. Psychological Reports, 72, 764-766.

Peterson PL, Ostrow DG, McKirnan DJ. (1991). Behavioral interventions for the primary prevention of HIV infection among homosexual and bisexual men, Journal Primary Prevention, 12, 19-34.

Simon PA, Hu DJ, Diaz T, Kerndt PR (1995). Income and AIDS rates in Los Angles Country. AIDS, 9, 281-284.

Wang MQ, Collins CB, Wingood, GM, DiClemente, RJ & Kohler CL (2000). Drug use and HIV risk related sex behaviors: A street outreach study of Black Adults, Southern Medical Journal, 93(2), 186-191.

Wang, M. Q., Fitzhugh, E., & Westerfield, R. C. (1995). Determining sample size for simple-random surveys. Health Values, 19, 53-56.

Wilson, T. E., Massad, L. S., & Riester K. A. (1999). 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. AIDS, 13(5), 591-598.

HEALTH EDUCATION RESPONSIBILITY AND COMPETENCY ADDRESSED

Responsibility I--Assessing Individual and Community Needs for Health Education

Competency B--Distinguish between behaviors that foster and those that hinder well-being.

Sub-competency 1--Investigate physical, social, emotional, and intellectual factors influencing health behavior.

Joseph Schumacher, Ph.D. is an Associate Professor in the Division of Preventive Medicine at the University of Alabama at Birmingham. Min Qi Wang, Ph.D. is a Professor in the Department of Public and Community Health at the University of Maryland. Sacia Dear, M.A. is the project coordinator at the University of Alabama at Birmingham. Sapna Marepally, B.S. is a master's student in the Department of Public and Community Health at the University of Maryland. Foster Cook, M.A. is art Associate Professor at the University of Alabama at Birmingham, and the director of the Substance Abuse Programs in the Department of Psychiatry. Address all corresponding Joseph Schumacher, Ph.D., The University of Alabama at Birmingham School of Medicine, 1717 11th Ave. South, Medical Towers Bld. 6th Floor, Birmingham, Alabama, 25205, PHONE: [phone], E-MAIL: [e-mail].

This study was supported in part by a grant from the Center for Substance Abuse Treatment/SAMHSA (Substance Abuse and Mental Health Services Administration).