The sex industry, alcohol and illicit drugs: implications for the spread of HIV infection

Women and substance use: a qualitative study on sexual and reproductive health of women who use drugs in Delhi, India

OBJECTIVES

To explore contextual factors that increase vulnerabilities to negative sexual and reproductive health (SRH) outcomes and possible differences in SRH-related behaviours and the needs of women who use drugs (WUD) through non-injecting and injecting routes.

DESIGN

Qualitative study design using semi-structured in-depth interviews.

PARTICIPANTS

Twenty women who injected drugs in the past 3 months and 28 women who reported using drugs through non-injecting routes in the past 1 month.

SETTING

Interviews were conducted at community-based, drop-in centres in Delhi, India.

RESULTS

Study findings illustrate that WUD were sexually active and had multiple sex partners including clients of sex work. Transient relationships were reported and many participants engaged in unsafe sex. Factors which affected safe sex behaviours included: gender power imbalance, limited agency for decision-making, lack of accurate information for correct self-risk assessment, and being under the influence of drugs. Despite high awareness, low and inconsistent contraceptive use was reported. Some participants were coerced to conceive while a few others reported their inability to conceive. Violence was a key determinant for SRH outcomes. Perception of certain adverse health outcomes (such as infertility) to be 'common and expected among WUD' influenced access to healthcare. Further, healthcare providers' stigmatising attitudes and lack of women-centric services deterred women from uptake of healthcare services.

CONCLUSION

Findings highlight that SRH-related behaviours and needs of this group are a complex interplay of multiple determinants which need to be addressed at all levels: individual, family, community and institutional. It is imperative to roll out a 'one-stop-shop' for a comprehensive package of health services. Expansion of existing drop-in-centres could be considered for setting-up community-based women-centric services with appropriate linkage to drug dependence treatment and reproductive health services.

High Levels of Persistent Problem Drinking in Women at High Risk for HIV in Kampala, Uganda: A Prospective Cohort Study

The aim of this study was to describe the epidemiology of problem drinking in a cohort of women at high-risk of HIV in Kampala, Uganda. Overall, 1027 women at high risk of HIV infection were followed from 2008 to 2013. The CAGE and AUDIT questionnaires were used to identify problem drinkers in the cohort. Interviewer-administered questionnaires were used to ascertain socio-demographic and behavioural factors. Blood and genital samples were tested for HIV and other sexually transmitted infections. At enrollment, most women (71%) reported using alcohol at least weekly and about a third reported having drunk alcohol daily for at least 2 weeks during the past 3 months. Over half (56%) were problem drinkers by CAGE at enrollment, and this was independently associated with vulnerability (being divorced/separated/widowed, less education, recruiting clients at bars/clubs, and forced sex at first sexual experience). Factors associated with problem drinking during follow-up included younger age, meeting clients in bars/clubs, number of clients, using drugs and HSV-2 infection. HIV prevalence was associated with drinking at enrollment, but not during follow-up. This longitudinal study found high levels of persistent problem drinking. Further research is needed to adapt and implement alcohol-focused interventions in vulnerable key populations in sub-Saharan Africa.

Sex Trading Among Hazardously Drinking Jailed Women

For women involved in sex trading, both alcohol problems and passage through the criminal justice system are highly prevalent. This study is the first to conduct a focused examination of factors associated with sex trading among hazardously drinking, pretrial, jailed women. Cocaine use, social support for alcohol abstinence, and more days incarcerated in the 90 days leading up to the index incarceration were significantly associated with sex trading involvement among alcoholic women. Helping incarcerated alcoholic women reduce cocaine use and improve sober support networks during and following an incarceration may minimize sex trading after release.

Injecting Drug Use Among Mexican Female Sex Workers on the US-Mexico Border

Both injecting drug users (IDU) and sex workers are at great risk of contracting and transmitting HIV. Therefore, IDU sex workers could be at especially high risk. The recent increase of HIV infection in Mexico has caused increased attention to sex work. We identify the correlates of injecting drug use including socio-demographic, work history, and sexual and non-injecting drug use risk behaviors among Mexican female sex workers. There is a high risk profile for IDUs compared to never injectors including a high prevalence of lifetime STI infection (54.2%). Revealed is an environment composed of high-risk networks that may have serious binational public health implications.

Drinking in social groups. Does 'groupdrink' provide safety in numbers when deciding about risk?

AIMS

To investigate the impact of alcohol consumption on risk decisions taken both individually and while part of a four- to six-person ad-hoc group.

DESIGN

A 2 (alcohol: consuming versus not consuming alcohol) × 2 (decision: individual, group) mixed-model design; decision was a repeated measure. The dependent variable was risk preference, measured using choice dilemmas.

SETTING

Opportunity sampling in campus bars and a music event at a campus-based university in the United Kingdom.

PARTICIPANTS

A total of 101 individuals were recruited from groups of four to six people who either were or were not consuming alcohol.

MEASUREMENTS

Participants privately opted for a level of risk in response to a choice dilemma and then, as a group, responded to a second choice dilemma. The choice dilemmas asked participants the level of accident risk at which they would recommend someone could drive while intoxicated.

FINDINGS

Five three-level multi-level models were specified in the software program HLM 7. Decisions made in groups were less risky than those made individually (B = -0.73, P < 0.001). Individual alcohol consumers opted for higher risk than non-consumers (B = 1.27, P = 0.025). A significant alcohol × decision interaction (B = -2.79, P = 0.001) showed that individual consumers privately opted for higher risk than non-consumers, whereas risk judgements made in groups of either consumers or non-consumers were lower. Decisions made by groups of consumers were less risky than those made by groups of non-consumers (B = 1.23, P < 0.001).

CONCLUSIONS

Moderate alcohol consumption appears to produce a propensity among individuals towards increased risk-taking in deciding to drive while intoxicated, which can be mitigated by group monitoring processes within small (four- to six-person) groups.

Correlates of self-efficacy for condom use among male clients of female sex workers in Tijuana, Mexico

Male clients of female sex workers (FSWs) in Tijuana, Mexico engage in high levels of unprotected sex. While behavioral change theories posit that self-efficacy predicts condom use, correlates of self-efficacy for condom use remain largely unstudied. We examined these correlates among male clients of FSWs in Tijuana. Eligible male clients were at least 18 years of age, HIV-negative, lived in Tijuana or San Diego, reported unprotected sex with a Tijuana FSW at least once in the past 4 months, and agreed to be treated for sexually transmitted infections (STIs). Participants completed an interviewer-administered questionnaire including demographics, substance use, psychosocial and psychosexual characteristics (e.g., outcome expectancies for negotiation of safer sex, social support, and sexual sensation seeking), and sexual behaviors. Participants also underwent HIV/STI testing. A stepwise hierarchical multiple regression analysis identified correlates of self-efficacy for condom use. Of 393 male clients, median age was 37 years. Participants were mostly Spanish-speaking and employed. Factors independently associated with higher self-efficacy for condom use were higher positive outcome expectancies for negotiation of safer sex, lower sexual sensation seeking scores, and higher social support scores. Both psychosocial and psychosexual factors may influence self-efficacy for condom use among male clients of FSWs. These factors represent central constructs in sociocognitive models that explain behavioral change and could be intervention targets for improving self-efficacy for condom use and, ultimately, safer sex behavior.

Sex work and its associations with alcohol and methamphetamine use among female bar and spa workers in the Philippines

To assess the prevalence of sex work and its associations with substance use among female bar/spa workers in the Philippines (N = 498), workers from 54 bar or spa venues in Metro Manila (2009-2010) were surveyed on demographics, drug/alcohol use, abuse history, and sex work. Their median age was 23 years and 35% engaged in sex work. Sex work was independently associated with methamphetamine use (19% vs 4%; adjusted odds ratio [AOR] =2.9, 95% confidence interval [CI] = 1.3-6.2), alcohol use with patrons (49% vs. 27%; AOR = 1.9, 95% CI = 1.1-3.4), and alcohol intoxication during sex (50% vs. 24%; AOR = 2.0, 95% CI = 1.2-3.5), but inversely associated with daily alcohol use (13% vs. 16%; AOR = 0.2, 95% CI = 0.1-0.5). Additional significant covariates included sexual abuse history, younger age, and not having a higher education. Findings suggest that interventions with sex workers in bars and spas should focus on methamphetamine use, alcohol use contexts, and violence victimization, to better meet the needs of this population.

Factors associated with history of drug use among female sex workers (FSW) in a high HIV prevalence state of India

Background

The intersection between illicit drug use and female commercial sex work has been identified as an important factor responsible for rising HIV prevalence among female sex workers (FSW) in several northeastern states of India. But, little is know about the factors associated with the use of drugs among FSWs in this region. The objective of the paper was to describe the factors associated with history of drug use among FSWs in Dimapur, an important commercial hub of Nagaland, which is a high HIV prevalence state of India.

Methods

FSWs were recruited using respondent driven sampling (RDS), and were interviewed to collect data on socio-demographic characteristics and HIV risk behaviours. Biological samples were tested for HIV, syphilis gonorrhea and Chlamydia. Logistic regression analysis was performed to identify factors associated with drug use.

Results

Among the 426 FSWs in the study, about 25% (n = 107) reported having ever used illicit drugs. Among 107 illicit drug users, 83 (77.6%) were non-injecting and 24 (22.4%) were injecting drug users. Drug-using FSWs were significantly more likely to test positive for one or more STIs (59% vs. 33.5%), active syphilis (27.1% vs. 11.4%) and Chlamydia infection (30% vs. 19.9%) compared to their non-drug using peers. Drug-using FSWs were also significantly more likely to be currently married, widowed or separated compared with non-drug-using FSWs. In multiple logistic regression analysis, being an alcohol user, being married, having a larger volume of clients, and having sexual partners who have ever used or shared injecting drugs were found to be independently associated with illicit drug use.

Conclusions

Drug-using FSWs were more vulnerable to STIs including HIV compared to their non-drug using peers. Several important factors associated with being an FSW who uses drugs were identified in this study and this knowledge can be used to plan more effectively targeted harm reduction strategies and programs.

Alcohol use among female sex workers and male clients: an integrative review of global literature

AIMS

To review the patterns, contexts and impacts of alcohol use associated with commercial sex reported in the global literature.

METHODS

We identified peer-reviewed English-language articles from 1980 to 2008 reporting alcohol consumption among female sex workers (FSWs) or male clients. We retrieved 70 articles describing 76 studies, in which 64 were quantitative (52 for FSWs, 12 for male clients) and 12 qualitative.

RESULTS

Studies increased over the past three decades, with geographic concentration of the research in Asia and North America. Alcohol use was prevalent among FSWs and clients. Integrating quantitative and qualitative studies, multilevel contexts of alcohol use in the sex work environment were identified, including workplace and occupation-related use, the use of alcohol to facilitate the transition into and practice of commercial sex among both FSWs and male clients, and self-medication among FSWs. Alcohol use was associated with adverse physical health, illicit drug use, mental health problems, and victimization of sexual violence, although its associations with HIV/sexually transmitted infections and unprotected sex among FSWs were inconclusive.

CONCLUSIONS

Alcohol use in the context of commercial sex is prevalent, harmful among FSWs and male clients, but under-researched. Research in this area in more diverse settings and with standardized measures is required. The review underscores the importance of integrated intervention for alcohol use and related problems in multilevel contexts and with multiple components in order to effectively reduce alcohol use and its harmful effects among FSWs and their clients.

Correlates of injection drug use among female sex workers in two Mexico-U.S. border cities

OBJECTIVE

To characterize the overlap between injection drug use and sex work by women in Tijuana and Cd. Juarez, situated on the Mexico-U.S. border.

METHODS

FSWs aged > or =18 years who were not knowingly HIV-positive and reported having unprotected sex with > or =1 client in the prior 2 months underwent interviews and testing for HIV, syphilis, gonorrhea and Chlamydia. Logistic regression identified factors associated with injecting drugs within the last month.

RESULTS

Of 924 FSWs, 18.0% had ever injected drugs. Among FSW-IDUs (N=114), prevalence of HIV, syphilis titers > or =1:8, gonorrhea and Chlamydia was significantly higher at 12.3%, 22.7%, 15.2% and 21.2% compared to 4.8%, 13.1%, 5.2% and 11.9% among other FSWs (N=810). FSW-IDUs also had more clients in the past 6 months (median: 300 versus 240, p=0.02). Factors independently associated with injecting drugs in the past month included living in Tijuana, being younger, being married/common-law, longer duration in the sex trade, speaking English, earning less for sex without condoms, often using drugs before sex, and knowing other FSWs who injected drugs.

CONCLUSIONS

FSW-IDUs had higher STI levels, engaged in riskier behaviors and were more vulnerable to having unsafe sex with clients compared to other FSWs, indicating that this subgroup is an important bridge population requiring focused prevention.

Alcohol use before sex and HIV acquisition: a longitudinal study in Rakai, Uganda

OBJECTIVE

To examine the association between alcohol use and HIV acquisition.

DESIGN AND METHODS

We examined alcohol use before sex and incident HIV in a population-based cohort in Rakai, Uganda, between 1994 and 2002. Adjusted incidence rate ratios (adjIRR) of HIV acquisition and 95% confidence intervals (CI) were estimated by Poisson multivariate regression. We also estimated adjusted prevalence rate ratios to assess the association between alcohol use and the number of sex partners and consistency of condom use.

RESULTS

In 6791 men and 8084 women HIV incidence was 1.4 per 100 person-years and 1.5 per 100 person-years, respectively. After adjustment for sociodemographic and behavioral factors, the risks of HIV when one partner consumed alcohol before sex were: adjIRR 1.67, 95% CI 1.17-2.40 among men, and adjIRR 1.40, 95% CI 1.02-1.92 among women, and when both partners consumed alcohol the risks were adjIRR 1.58, 95% CI 1.13-2.21 among men, and adjIRR 1.81, 95% CI 1.34-2.45 among women. Alcohol use was significantly associated with inconsistent condom use and multiple sexual partners in both sexes.

CONCLUSION

The use of alcohol before sex increases HIV acquisition. A reduction of alcohol use should be incorporated into HIV prevention programmes.

HIV, HBV, and HCV infections among drug-involved, inner-city, street sex workers in Miami, Florida

This study describes the rates of HIV, HBV, and HCV seropositivity among drug-involved, female street sex workers in low-income, inner-city sections of Miami, Florida; further, their sociodemographic characteristics, drug use, and sexual risk behaviors were assessed; and predictors of infection were reported. A sample of 586 sex workers was recruited through targeted sampling methods, interviewed, and counseled and tested for the presence of antibody to HIV, HBV, and HCV. Respondents' median age was 38 years, median time in sex work was 14 years, all were heavily involved in the use of alcohol and drugs, and 42% were homeless. More than half (51.0%) had engaged in unprotected vaginal sex in the past month. Prevalences were HIV, 22.4%; HBV, 53.4%; HCV, 29.7%. A multidimensional public health program must address not only issues related to unsafe sex, but also the problems of drug abuse, homelessness, and other lifestyle factors that contribute to risk behaviors.

Drug use and risk behaviours among injecting drug users: a comparison between sex workers and non-sex workers in Sydney, Australia

Background

This paper examines the differences in demographics, drug use patterns and self reported risk behaviours between regular injecting drug users (IDU) who report engaging in sex work for money or drugs and regular injecting drug users who do not.

Methods

Cross sectional data collected from regular IDU interviewed as part of the New South Wales (NSW) Illicit Drug Reporting System (IDRS) in 2003 were analysed.

Results

IDU who reported engaging in sex work were more likely to be female, and identify as being of Aboriginal and/or Torres Strait Islander descent. They initiated injecting drug use at a significantly younger age and were more likely to report injection related problems than IDU who had not engaged in sex work. There were no differences in the drug classes used, but findings suggested that the sex workers tended to be more frequent users of crystalline methamphetamine (ice) and benzodiazepines.

Conclusion

The similarities between these groups were more striking than the differences. Further research, examining a larger sample is needed to clarify whether injecting drug users who are sex workers have heavier use patterns.

Prostitution, Drug Use, and Coping with Psychological Distress

The purpose of this study was to explore the severity of substance abuse and reasons for using drugs among prostituting African American women who smoke crack cocaine. Specifically, we were interested in examining whether prostitutes use drugs as a means of coping with intra- and interpersonal experiences commonly associated with their occupation. Using a convenience sample of 203 African American women with a history of crack smoking, participants were interviewed and asked a variety of questions including whether they had ever engaged in prostitution as a source of income and the severity of and reasons for their drug use. Women who were prostituting, in contrast to those who were not, were found to have a significantly higher severity of drug use and were significantly more likely to use drugs to increase confidence, control, and closeness to others and to decrease feelings of guilt and sexual distress. We argue that women may enter prostitution in order to fund their drug use; however, prostitutes likely increase their drug use in order to deal with distress caused by activities associated with their occupation. The need to address the mental health issues of prostitutes who are abusing illicit drugs is discussed.

Sex trading and psychological distress in a street-based sample of low-income urban men

This article examines the relationship between sex trading and psychological distress and assesses sexual human immunodeficiency virus (HIV) risk behaviors and HIV seroprevalence in a sample of young men recruited from the streets of Harlem. The authors interviewed 477 men, aged 18 to 29 years, of whom 43 (9.0%) had received money or drugs in exchange for sex in the preceding 30 days and were categorized as sex traders. Psychological distress was measured by using the Brief Symptom Inventory (BSI). Sex traders scored significantly higher than non-sex traders on the General Severity Index and on all nine subscales of the BSI. According to multivariate analysis after adjusting for perceived HIV risk, current regular crack cocaine use and homelessness, sex traders scored 0.173 units higher on the General Severity Index than non-sex traders (p < .001). More of the sex traders tested positive for HIV (41% versus 19%, p < .001). The alarmingly high HIV seroprevalence rate in sex traders in this sample underscores the need to redouble HIV prevention efforts for this population. The high levels of psychological distress and crack cocaine dependence among sex traders may undermine their ability to adopt safer sex behaviors and should be considered in intervention designs.

Prostitution, violence, and posttraumatic stress disorder

One hundred and thirty people working as prostitutes in San Francisco were interviewed regarding the extent of violence in their lives and symptoms of posttraumatic stress disorder (PTSD). Fifty-seven percent reported that they had been sexually assaulted as children and 49% reported that they had been physically assaulted as children. As adults in prostitution, 82% had been physically assaulted; 83% had been threatened with a weapon; 68% had been raped while working as prostitutes; and 84% reported current or past homelessness. We differentiated the types of lifetime violence as childhood sexual assault; childhood physical abuse; rape in prostitution; and other (non-rape) physical assault in prostitution. PTSD severity was significantly associated with the total number of types of lifetime violence (r = .21, p = .02); with childhood physical abuse (t = 2.97, p = .004); rape in adult prostitution (Student's t = 2.77, p = .01); and the total number of times raped in prostitution (Kruskal-Wallace chi square = 13.51, p = .01). Of the 130 people interviewed, 68% met DSM III-R criteria for a diagnosis of PTSD. Eighty-eight percent of these respondents stated that they wanted to leave prostitution, and described what they needed in order to escape.

The high-risk sexual practices of crack-smoking sex workers recruited from the streets of three American cities. The Multicenter Crack Cocaine and HIV Infection Study Team

BACKGROUND AND OBJECTIVES

Small ethnographic and clinic-based studies indicate that crack-smoking sex workers are at high risk for human immunodeficiency virus (HIV) and sexually transmitted diseases (STD).

STUDY GOALS

To examine the prevalence of risky sexual behaviors and HIV and STD in a large sample of street-recruited crack-smoking sex workers.

STUDY DESIGN

From 1991 to 1992, 419 crack-smoking sex workers were recruited from urban neighborhoods, interviewed, and serologically tested.

RESULTS

Many female and male sex workers reported sex with injectors (30% to 41%) or HIV-infected persons (8% to 19%), past STD (73% to 93%), and inconsistent condom use (> 50% for all types of sex). Sex workers who worked in crack houses or vacant lots, were paid with crack, or injected drugs had the riskiest sex practices. Most sex workers initiated sex work before they first smoked crack. More than 25% were infected with HIV (27.9%), syphilis (37.5%), or herpes simplex virus type 2 (66.8%).

CONCLUSIONS

Interventions to prevent HIV/STD transmission among crack-smoking sex workers are urgently needed.

Sex trading and psychological distress among women recruited from the streets of Harlem

OBJECTIVES

This study examines the relationship between sex trading and psychological distress and the implications of that relationship for prevention of human immunodeficiency virus among a sample of young women recruited from the streets of Harlem.

METHODS

Interviews were conducted with 346 predominantly drug-using women, aged 18 to 29 years, of whom 176 had exchanged sex for money or drugs in the previous 30 days and were categorized as "sex traders." Psychological distress was measured by using the Brief Symptom Inventory.

RESULTS

Sex traders scored significantly higher than non-sex traders on the General Severity Index and on eight of the nine subscales of the Brief Symptom Inventory. Multivariate analysis indicated that after adjustments were made for age; ethnicity; pregnancy; recent rape; perceived risk for acquired immunodeficiency syndrome; current, regular crack use; and current, regular alcohol use, sex traders scored 0.240 units higher on the General Severity Index than non-sex traders.

CONCLUSIONS

Poor mental health and drug dependence may under-mine the motivation and ability of these sex traders to adopt safer sex behavior. Therefore, interventions need to be integrated with mental health services and drug treatment to reduce risk behavior in this population.

Sexual behaviour of drug injectors in London: implications for HIV transmission and HIV prevention

The importance of sharing injecting equipment in the transmission dynamics of HIV is well established. Comparatively less is known about the sexual behaviour of drug injectors and the risks posed to themselves and their sexual partners through the sexual transmission of HIV. Findings are reported from survey-based interviews undertaken in 1991 which investigated the sexual behaviour of 516 drug injectors, both in and out of treatment in London. The majority of respondents (80%) were sexually active in the 6 months preceding interview. During this time, respondents had a mean of 2.1 non-commercial opposite sex partners. Most (66%) had vaginal intercourse at least once a week, although 68% never used condoms with primary partners and 34% never used condoms with casual partners. Those having sexual intercourse most often were less likely to use condoms. Many had non-injecting sexual partners, and 62% of respondents' primary and casual partners did not inject drugs. Confirmed saliva HIV test results show 10% of respondents to be antibody positive, with a higher rate of prevalence (14% positive) among those with no experience of treatment. This group were also more likely to report casual sexual intercourse. The average rate of partner change, the high proportion of drug injectors with non-injecting partners and the infrequency of condom use within primary and causal relationships indicates the potential for HIV transmission between injectors and their non-injecting sexual partners. The paper concludes by emphasizing the importance of outreach and community-based intervention in safer sex health promotion.

Should wider HIV testing be encouraged on the grounds of HIV prevention?

The issue of the role of HIV testing in HIV prevention is an important one. Some commentators have argued that HIV testing should be encouraged more widely on the grounds that it can stimulate behaviour change to safe sex and drug use. Testing has been advanced as an important means to control the epidemic. There is, however, insufficient evidence to support this contention at this time. The hypothesis of a link between HIV testing and behaviour change is based on the assumption of a linear relationship. It is argued that this assumption is based on two others, that the 'stimulus' of testing and counselling is uniform, and that information will be perceived and used by all recipients in an identical way. It is argued that there is currently insufficient research evidence to encourage more widespread testing on prevention grounds. Issues which should be considered in future research designs are discussed.

AIDS and STDs: risk behaviour patterns among female sex workers in Bali, Indonesia

This study investigated AIDS and STD knowledge, risk behaviour patterns and condom use among three distinct groups of female commercial sex workers (CSWs) in Bali, Indonesia. Individual in-depth interviews were conducted with 71 female CSWs. These CSW groups differ in the prices they charge, their places and modes of employment, educational backgrounds, levels of AIDS and STD knowledge, number of clients served and levels of condom use. Knowledge of the routes of transmission and appropriate prevention practices is low among all groups, and despite significant differences in their number of clients and their condom use, all groups report high levels of STD symptoms. Although HIV seroprevalence rates are currently low in Indonesia, high risk sexual behaviour patterns place all three groups of CSWs and their clients at great risk of infection. Interventions targeted to specific groups of CSWs and clients should be undertaken as soon as possible, including educational activities utilizing peer educators, condom promotion and distribution, together with improved STD diagnosis and treatment for CSWs and their clients.

Barriers to human immunodeficiency virus related risk reduction among male street prostitutes

Two hundred eleven male street prostitutes between the ages of 18 and 51 years were interviewed and tested for antibodies to the human immunodeficiency virus (HIV). Economic, social, and emotional barriers to the reduction of HIV-related risk behavior were examined within the context of several concepts present in the Health Belief Model (HBM). Three lifestyle factors were found to function as barriers to engaging in risk reduction behavior. Subjects who were more economically dependent on prostitution, perceived less control over the hustling encounter, and reported increased pleasure from sexual activity with their customers were more likely to engage in risk-taking behavior. Prostitutes' perception of the severity of HIV infection was not significantly associated with their risk behavior. Unexpected findings indicated that increases in perceived susceptibility to HIV and perceived benefit of condom use for HIV prevention were significantly related to increased risk-taking behavior. Practical applications of findings in the design and implementation of future HIV-related preventive health education programs are discussed.

Severity of heroin dependence and HIV risk. I. Sexual behaviour

The HIV risks associated with the sexual behaviour of drug injectors have sometimes been overshadowed by the more obvious risks of injection behaviour. In this study, 408 heroin users were interviewed in the community; 50% were not currently in treatment and 42% had never had any treatment contact. In addition to data on drug use, information was collected on sexual risk behaviour by means of a linked anonymous questionnaire (96% returned). Eighty-nine per cent of the sample had had at least one sexual partner in the previous year and 58% had a regular sexual partner at the time of interview. Drug users who had a sexual partner who was injecting drugs were more severely dependent upon heroin. Twenty-three per cent of the men and 20% of the women reported having had anal intercourse in the previous year. Seventeen per cent of the women and 6% of the men had engaged in some form of prostitution. Severity of heroin dependence was positively related to the occurrence and to the frequency of sex-for-money transactions and to the less well recognized phenomenon of sex-for-drugs; this association with severity of dependence applied to the women and to the men who have sex with men. The overall level of condom use was low in this sample, though condom use was more frequent among those involved in sex-for-money or sex-for-drugs transactions. Low levels of condom use were reported even for such high risk activities as anal sex.(ABSTRACT TRUNCATED AT 250 WORDS)

Substance use/misuse among female prostitutes and female arrestees

The literature has documented the correlation between prostitution and drug use/misuse. This study probed demographics, drug use experimentation and frequency, age of first drug use, and drug use treatment among 53 female prostitutes and 47 female arrestees. The results indicated that: 1) prostitutes were likely to drop out of school; 2) significantly more prostitutes had tried drugs, had used drugs with greater frequency and had begun drug/alcohol use at younger ages. These results imply that: 1) early drug/alcohol use and withdrawal from school could leave young women vulnerable and at higher risk of becoming involved in prostitution; and 2) drug use treatment and intervention needs to begin at younger ages.

Exchanging sex for crack-cocaine: a comparison of women from rural and urban communities

Studies of the HIV risks of crack-cocaine using women have focused on those living in the inner city, urban areas of the country. However, reports indicate that the rates of syphilis and HIV infection have shown greater increases in rural areas than in urban ones. This paper reports the findings of a comparative study of 60 female crack-cocaine users, 25 from rural southeast Georgia and 35 from Miami, Florida, to determine their drug using and sexual practices, as well as their knowledge about AIDS and HIV transmission. Their patterns of initial and continuous drug use were similar, as were their sexual practices. However, the Miami women were more likely to have had a greater number of sexual partners than the Georgia women. Both groups were knowledgeable about AIDS and the transmission of HIV, yet all participated in activities that put them at high risk for HIV infection and transmission. Some 12 percent of the 60 respondents reported testing positive for HIV. The study suggests that at least within these populations, there are few differences between rural and urban crack using women in terms of their crack use, sexual practices, and potential for HIV infection and transmission.

Sex, HIV and the injecting drug user

There is considerable evidence that drug injectors are reducing their HIV risk, but changes in syringe sharing behaviour have been greater than those in sexual risk behaviour. This paper reviews the literature on sexual risk behaviour in injecting drug users. It focuses on the major areas of concern: HIV prevalence among drug injectors; sexual risk behaviour; the potential for heterosexual transmission; condom use; sexual risk and women; pregnancy; male homosexual activity and drug use; the effect of drugs on sexual behaviour and prostitution. The paper also considers some of the difficulties in changing sexual risk behaviour and suggests some ways forward for intervention and prevention.

Alcohol, AIDS risks and sex industry clients: results from a Scottish study

During 1988 and 1989 self-reported data were obtained from 206 males and three females who had paid for physical sexual services. Respondents were contacted by "snowballing", mainly with the assistance of sex workers. The study group reported that both alcohol and illicit drug use were commonplace during their contact with prostitutes. No general association between alcohol and drug use and 'risky sex' was evident. Even so amongst males who had anal sex with males alcohol consumption was inversely related to condom use.

Alcohol, AIDS risks and commercial sex: some preliminary results from a Scottish study

During 1988 self-report data were elicited from a study of 102 male and 103 female sex workers (prostitutes) in Edinburgh. Respondents were contacted by 'snowballing', mostly in licensed premises. This was reflected by high levels of self-reported alcohol and illicit drug use. Respondents reported that both alcohol and illicit drug use were commonplace in relation to their work and that many of their clients were under alcohol or drug effect at the time of contact. Condom use was unrelated to sex workers' alcohol or drug use, but was significantly associated with sex workers' assessments of the proportions of their clients also under the influence of illicit drugs.

Risks of AIDS among workers in the "sex industry": some initial results from a Scottish study

OBJECTIVE

To determine the extent to which workers in the "sex industry" in Edinburgh engage in activities with a high risk of infection with HIV.

DESIGN

Cross sectional, single phase survey in which respondents were located by a non-random method ("snowballing").

SETTING

Research project coordinated by the Alcohol Research Group, Edinburgh.

SUBJECTS

205 Sex workers (102 male, 103 female) interviewed between July and December 1988.

END POINT

Strategies to reduce risk of AIDS among people who buy and sell sexual services.

MEASUREMENTS AND MAIN RESULTS

Data were elicited by a standardised interview which related to over 300 variables. A fifth of the study group had used drugs intravenously, and one in 12 reported that they had been found to be seropositive on HIV testing. Roughly a quarter of the study group sometimes engaged in unprotected sex with clients for more money, and a similar proportion sometimes did not seek medical advice even if they had genital or anal symptoms.

CONCLUSIONS

People who buy and sell sexual services should be priority targets for health education and strategies to reduce their risk of AIDS.

Psychoactive substance use and related behaviours of 135 regular illicit drug users in Scotland

Using a 'snowballing' technique, prospective data have been collected from 135 regular drug using individuals in two Scottish towns, Edinburgh, and Ayr. Data from the first wave would suggest that poly drug use is common, with a major reliance on licit, prescribed substances. Amongst both intravenous and non-intravenous drug users, awareness and concern about HIV/AIDS would not appear to have produced significant changes in sexual behaviour. Furthermore, responses from intravenous users indicate that there has been no large scale adoption of safer injection techniques.