Changes in women's sexual risk behaviors after therapeutic community treatment

A retrospective and prospective analysis of trading sex for drugs or money in women substance abuse treatment patients

BACKGROUND

Trading sex for drugs or money is common in substance abuse treatment patients, and this study evaluated prevalence and correlates of this behavior in women with cocaine use disorders initiating outpatient care. In addition, we examined the relation of sex trading status to treatment response in relation to usual care versus contingency management (CM), as well as predictors of continued involvement in sex trading over a 9-month period.

METHODS

Women (N=493) recruited from outpatient substance abuse treatment clinics were categorized according to histories of sex trading (n=215, 43.6%) or not (n=278).

RESULTS

Women with a history of trading sex were more likely to be African American, older and less educated, and they had more severe employment problems and were more likely to be HIV positive than those without this history. Controlling for baseline differences, both groups responded equally to substance abuse treatment in terms of retention and abstinence outcomes. Fifty-four women (11.3%) reported trading sex within the next nine months. Predictors of continued involvement in trading sex included a prior history of such behaviors and achieving less abstinence during treatment. Each additional week of abstinence during treatment was associated with a 16% reduction in the likelihood of trading sex over the follow-up.

CONCLUSIONS

Because over 40% of women receiving community-based treatment for cocaine use disorders have traded sex for drugs or money and more than 10% persist in the behavior, more intensive and directed approaches toward addressing this HIV risk behavior are recommended.

Growth in alcohol use as a developmental predictor of adolescent girls' sexual risk-taking

Adolescent sexual risk-taking is common and often occurs under the influence of alcohol. Although alcohol use emerges in early adolescence, there is little empirical research examining whether growth in alcohol use during this developmental period predicts later risky sexual behavior. Such information could provide a critical opportunity for the prevention of sexually transmitted infections and unwanted teenage pregnancies. The current study examined alcohol use as a developmental mediator of the relationship between conduct problems, impulsivity, poverty, race and menarche assessed at age 11, and sexual risk-taking among girls at age 16. The sample comprised 499 participants of the Pittsburgh Girls Study (57.7% African American and 42.3% European American) interviewed annually for 6 years between age 11 and 16. The results of the conditioned latent growth curve model showed that the rate of increase in alcohol use, and African American race, predicted higher rates of sexual risk-taking at age 16. However, European American race predicted the intercept and slope of alcohol use. When mediation was tested, the results showed that age 12 use and an increase in propensity for alcohol use between 12 and 15 explained the relationship between European American race and later risky sex, but this was not the case for African American girls. Use of alcohol at age 12 also mediated the association between early menarche and subsequent sexual risk-taking. The implications of the findings for sexual risk prevention are discussed.

"Because he has bought for her, he wants to sleep with her": alcohol as a currency for sexual exchange in South African drinking venues

Previous research has documented the practice of transactional sex in sub-Saharan Africa and its association with gender-based violence, gender inequalities and HIV risk. At the same time, it has been suggested that women may use transactional sex to obtain a greater sense of control over their lives and their sexualities, and to garner access to resources. The aim of this study was to better understand the practice of exchanging alcohol for sex in alcohol-serving venues in a township in Cape Town, South Africa. Data were collected between June 2009 and October 2010. Six venues were included and observations were conducted in each for four one-week periods over the course of a year. In-depth qualitative interviews included 31 women and 13 men whom interviewers had observed as regular venue customers. Follow-up interviews were conducted with 24 respondents to explore emerging themes. Interviews were recorded and transcribed. Using a grounded theory approach, Atlas.ti was used to code transcripts, field notes, and analytical memos written about each document. Results revealed that alcohol was commonly used as a currency of sexual exchange in this setting, and both women and men understood that accepting alcohol from a man implied consent for sexual favors. Women reported a sense of agency in participating in the transactional sex dynamic, especially when they were able to manipulate it to meet their own ends without fulfilling the men's sexual expectations. At the same time, data revealed that the norm of transactional sex reinforced the undervaluing and commoditization of women. As identified elsewhere, transactional sex put both women and men at greater risk of HIV through multiple partners and inconsistent use of condoms, and the possibility of rape. Interventions are needed to address sexual risk behaviors and substance use within this context to prevent new HIV infections.

Causal links between binge drinking patterns, unsafe sex and HIV in South Africa: its time to intervene

South Africa has a massive burden of HIV and alcohol disease, and these pandemics are inextricably linked. Much evidence indicates that alcohol independently influences decisions around sex, and undermines skills for condom negotiation and correct use. Thus, not surprisingly, people with problem drinking in Africa have twofold higher risk for HIV than non-drinkers. Also, sexual violence incidents often coincide with heavy alcohol use, both among perpetrators and victims. Reducing alcohol harms necessitates both population- and individual-level interventions, especially raised taxation, regulation of alcohol advertising and provision of Brief Interventions. Alcohol counselling interventions must include discussion of linkages between alcohol and sex, and consequences thereof. Within positive-prevention services, alcohol reduction interventions could diminish HIV transmission. A trial is needed to definitively demonstrate that reduced drinking lowers HIV incidence. However, given available evidence, implementation of effective interventions could alleviate much alcohol-attributable disease, including unsafe sex, sexual violence, unintended pregnancy and, likely, HIV transmission.

Enhancing global control of alcohol to reduce unsafe sex and HIV in sub-Saharan Africa

Sub-Saharan Africa carries a massive dual burden of HIV and alcohol disease, and these pandemics are inextricably linked. Physiological and behavioural research indicates that alcohol independently affects decision-making concerning sex, and skills for negotiating condoms and their correct use. More than 20 studies in Africa have reported higher occurrence of HIV among people with problem drinking; a finding strongly consistent across studies and similar among women and men. Conflation of HIV and alcohol disease in these setting is not surprising given patterns of heavy-episodic drinking and that drinking contexts are often coterminous with opportunities for sexual encounters. HIV and alcohol also share common ground with sexual violence. Both perpetrators and victims of sexual violence have a high likelihood of having drunk alcohol prior to the incident, as with most forms of violence and injury in sub-Saharan Africa. Reducing alcohol harms necessitates multi-level interventions and should be considered a key component of structural interventions to alleviate the burden of HIV and sexual violence. Brief interventions for people with problem drinking (an important component of primary health care), must incorporate specific discussion of links between alcohol and unsafe sex, and consequences thereof. Interventions to reduce alcohol harm among HIV-infected persons are also an important element in positive-prevention initiatives. Most importantly, implementation of known effective interventions could alleviate a large portion of the alcohol-attributable burden of disease, including its effects on unsafe sex, unintended pregnancy and HIV transmission.

Methadone patients in the therapeutic community: a test of equivalency

BACKGROUND

Residential therapeutic communities (TCs) have demonstrated effectiveness, yet for the most part they adhere to a drug-free ideology that is incompatible with the use of methadone. This study used equivalency testing to explore the consequences of admitting opioid-dependent clients currently on methadone maintenance treatment (MMT) into a TC.

METHODS

The study compared 24-month outcomes between 125 MMT patients and 106 opioid-dependent drug-free clients with similar psychiatric history, criminal justice pressure and expected length of stay who were all enrolled in a TC. Statistical equivalence was expected between groups on retention in the TC and illicit opioid use. Secondary hypotheses posited statistical equivalence in the use of stimulants, benzodiazepines, and alcohol, as well as in HIV risk behaviors.

RESULTS

Mean number of days in treatment was statistically equivalent for the two groups (166.5 for the MMT group and 180.2 for the comparison group). At each assessment, the proportion of the MMT group testing positive for illicit opioids was indistinguishable from the proportion in the comparison group. The equivalence found for illicit opioid use was also found for stimulant and alcohol use. The groups were statistically equivalent for benzodiazepine use at all assessments except at 24 months where 7% of the MMT group and none in the comparison group tested positive. Regarding injection- and sex-risk behaviors the groups were equivalent at all observation points.

CONCLUSIONS

Methadone patients fared as well as other opioid users in TC treatment. These findings provide additional evidence that TCs can be successfully modified to accommodate MMT patients.

Condom Use Self-Efficacy among Young Adult Ecstasy Users

Relying upon a sample of 283 young adult ecstasy users, this research examines three primary research questions: How high/low are young adult ecstasy users' levels of condom use self-efficacy? How does condom use self-efficacy relate to actual condom use in this population? What factors underlie condom efficacy levels in this population? The study entailed face-to-face interviews that were completed with the use of computer-assisted structured interviews (i.e., CASI). Study participants were recruited in the Atlanta, Georgia metropolitan area between August 2002 and August 2004 using a targeted sampling and ethnographic mapping approach. Interviews took approximately two hours to complete. Condom use self-efficacy levels were found to be fairly high in this population. A strong, direct relationship was observed between condom use self-efficacy and actual condom use. Using a multiple regression approach, five factors were found to be predictive of greater condom use self-efficacy in this population. These were educational attainment, amount of communication in one's family of origin, having asked about one's most recent casual sex partner's HIV serostatus, no prior drug treatment, and level of self-esteem.

HIV/AIDS risks among men and women who drink at informal alcohol serving establishments (Shebeens) in Cape Town, South Africa

HIV/AIDS is devastating southern Africa and the spread of HIV is fueled in some populations by alcohol use. Alcohol serving establishments, such as informal drinking places or shebeens, often serve as high-risk venues for HIV transmission. The current study examined the HIV risks of men (N = 91) and women (N = 248) recruited from four shebeens in a racially integrating township in Cape Town South Africa. Participants completed confidential measures of demographic characteristics, HIV risk history, alcohol and drug use, and HIV risk behaviors. Comparisons of 94 (28%) participants who reported meeting sex partners at shebeens to the remaining sample of shebeen goers, controlling for potential confounds, demonstrated a pattern of higher risk for HIV infection among persons who met sex partners at shebeens. Few differences, however, were observed between men (N = 47) and women (N = 47) who had met sex partners at shebeens, suggesting greater gender similarities than gender differences in this important subpopulation. These results indicate an urgent need for multi-level HIV prevention interventions targeting shebeens and the men and women who drink in these settings.

Identity and resilience among persons with HIV: a rural African American experience

In this article, the author contrasts the disruption model proposed by Becker (1997) against the life trajectories of two persons who used and sold drugs; considers the impact of engagement and discontinuation of substance use on their respective lives; and examines the process of life reorganization they put into motion after testing positive for HIV. Their departure from the world of drugs removed each from an unwanted lifestyle, facilitated the process of building resilience against the social adversity they faced in relation to their seropositivity, assisted them with securing care and services through institutional mechanisms, and generated a forum for new ideas on family continuity versus the ideal of individualism that grounds mainstream society. A process of identity reaffirmation further deepened their understanding of themselves as African Americans in the southern United States.

Alcohol use severity and HIV sexual risk among juvenile offenders

Guided by the Information Motivation Behavioral Skills (IMB) model, we examine the alcohol severity/sexual risk relationship for juvenile offenders who are at extreme risk for HIV/AIDS due to situational vulnerabilities, substance abuse,1 and personality factors. Sexual risk behavior was analyzed by levels of alcohol use among 634 ethnically diverse adolescents in Miami between 1998 and 2002. Adolescents with the highest levels of alcohol use reported significantly higher levels of total and unprotected sexual activity and sex acts proximate to drinking. Alcohol use related problems require more attention by HIV interventionists. Alcohol severity may reduce the effectiveness of HIV interventions that do not address concurrent substance use.