Behavior changes among crack-using rural and urban women

"I would do anything but that": Attitudes towards sex work among rural people who use drugs

BACKGROUND

Stigma towards people who use drugs and those who engage in sex work is well-documented, leading to consequences such as reduced access to health services and support, especially in rural milieus. Stigma reduction has been recognized as a priority in the opioid overdose crisis, but little attention has been paid to within-group attitudes and beliefs. This study aimed to explore how people who use drugs in rural counties across the United States appraise sex work by themselves or other community members.

METHODS

Qualitative interview data came from the Rural Opioid Initiative (ROI), a project coordinated by research teams across 65 rural counties in 10 states. Interviews were individual and conducted from 2018 to 2020. All participants reported past 30-day opioid use and/or any injection drug use. A working group coded the data, then used an iterative inductive-deductive approach to organize data into themes of stigma among people who use drugs, focusing on stigma towards sex work.

RESULTS

Across sites, 355 interviews were conducted. Mean participant age was 36, 55 % of participants were male, and 93 % were white. Participants expressed negative attitudes towards sex work as a function of its criminal-legal repercussions or framed sex work as morally transgressive. Many appraisals were gendered, with the behavior conveyed as being "easier" for women who were often described as "whores," with more neutral terms used to describe men. Some viewed sex work as an implicit "exchange" for drugs. Several participants noted a lack of agency as a feature leading to involvement in sex work, with partner power dynamics influencing an individual's behavior. Finally, a few participants acknowledged the circumstances under which they would newly engage in sex work.

CONCLUSION

We identified several patterns by which people who use drugs evaluate community members who sell sex. These included gendered and morally-charged forms of stigma, which may represent barriers to community acceptance and support among this subgroup.

Intervention Reach and Sexual Risk Reduction of a Multi-level, Community-Based HIV Prevention Intervention for Crack Users in San Salvador, El Salvador

This article examines the effects of a multi-level, community-based HIV prevention intervention for crack users residing in low-income neighborhoods in San Salvador, El Salvador conducted between August 2011 and June 2016. The intervention consisted of three components introduced sequentially: (1) rapid HIV testing in community settings; (2) a social network HIV testing intervention; and (3) small group interventions with crack users who were members of the same social network. The intervention was evaluated with an interrupted time series design in which we used respondent-driven sampling to conduct 7 cross-sectional surveys with crack users along a 3-4 month period for each assessment (total n = 1597). Results revealed a significant increase in exposure to the intervention over time with 50% of the participants reporting exposure to one or more of the three components. Getting an HIV test at the community site was associated with reductions in total times each individual had sex without a condom (p < 0.05) compared to those who had been exposed to no intervention components. Being referred by another crack user through the Social Network HIV intervention was also associated with reductions in total numbers of condomless sex (p < 0.05) The cumulative effect of being exposed to more than one intervention component was associated with reductions in total number of times individuals had condomless sex (p < 0.05). In spite of the high level of intervention reach and that self-reported exposure to intervention components was associated with lower sexual risk, reductions in sexual risk over time were not observed in the full sample, indicating that the penetration of HIV prevention components was not sufficient to produce population level change.

Effectiveness of secondary prevention and treatment interventions for crack-cocaine abuse: a comprehensive narrative overview of English-language studies

There are an estimated several million crack-cocaine users globally; use is highest in the Americas. Most crack users are socio-economically marginalized (e.g., homeless), and feature elevated risks for morbidity (e.g., blood-borne viruses), mortality and crime/violence involvement, resulting in extensive burdens. No comprehensive reviews of evidence-based prevention and/or treatment interventions specifically for crack use exist. We conducted a comprehensive narrative overview of English-language studies on the efficacy of secondary prevention and treatment interventions for crack (cocaine) abuse/dependence. Literature searches (1990-2014) using pertinent keywords were conducted in main scientific databases. Titles/abstracts were reviewed for relevance, and full studies were included in the review if involving a primary prevention/treatment intervention study comprising a substantive crack user sample. Intervention outcomes considered included drug use, health risks/status (e.g., HIV or sexual risks) and select social outcome indicators. Targeted (e.g., behavioral/community-based) prevention measures show mixed and short-term effects on crack use/HIV risk outcomes. Material (e.g., safer crack use kit distribution) interventions also document modest efficacy in risk reduction; empirical assessments of environmental (e.g., drug consumption facilities) for crack smokers are not available. Diverse psycho-social treatment (including contingency management) interventions for crack abuse/dependence show some positive but also limited/short-term efficacy, yet likely constitute best currently available treatment options. Ancillary treatments show little effects but are understudied. Despite ample studies, pharmaco-therapeutic/immunotherapy treatment agents have not produced convincing evidence; select agents may hold potential combined with personalized approaches and/or psycho-social strategies. No comprehensively effective 'gold-standard' prevention/treatment interventions for crack abuse exist; concerted research towards improved interventions is urgently needed.

Project Salud: Efficacy of a community-based HIV prevention intervention for Hispanic migrant workers in south Florida

Project Salud evaluates the efficacy of a community-based intervention to reduce risk behaviors and enhance factors for HIV-preventative behaviors. A randomized controlled trial of 278 high risk Latino migrant workers was conducted between 2008 and 2010. Participants completed an audio computer-assisted self-interview questionnaire at baseline and 3- and 9-month post-intervention follow-ups. Participants were randomly assigned to the community-based intervention (A-SEMI) or the health promotion condition (HPC). Both interventions consisted of four 2.5-hour interactive sessions and were structurally equivalent in administration and format. Relative to the comparison condition, A-SEMI participants reported more consistent condom use, were less likely to report never having used condoms, and were more likely to have used condoms at last sexual encounter during the past 90 and 30 days. A-SEMI participants also experienced a positive change in regard to factors for HIV-preventive behaviors over the entire 9-month period. Our results support the implementation of community-based, culturally tailored interventions among Latino migrant workers.

The Latino Migrant Worker HIV Prevention Program: building a community partnership through a community health worker training program

There is limited information on the impact of the HIV/AIDS epidemic on Latino migrant workers (LMWs), although available data indicate that this community is being disproportionally affected. The need for prevention programs that address the specific needs of LMWs is becoming well recognized. HIV prevention interventions that train and employ community health workers are a culturally appropriate way to address the issues of community trust and capacity building in this community. This article describes the Latino Migrant Worker HIV Prevention Program and its efforts to train and engage community health workers in the prevention of HIV among LMWs in South Florida.

Behavioral interventions for African Americans to reduce sexual risk of HIV: a meta-analysis of randomized controlled trials

CONTEXT

African Americans constitute 13% of the US population yet account for nearly 50% of new HIV infections. Implementation of efficacious behavioral interventions can help reduce infections in this vulnerable population.

OBJECTIVES

To examine the efficacy of behavioral interventions to reduce HIV for African Americans among 78 randomized controlled trials that sampled at least 50% African Americans (N = 48,585, 81% African American), measured condom use or number of sexual partners, and provided sufficient information to calculate effect sizes.

METHODS

Independent raters coded participant characteristics, design and methodological features, and intervention content. Weighted mean effect sizes, using both fixed- and random-effects models, were calculated; positive effect sizes indicated more condom use and fewer sexual partners.

RESULTS

Compared with controls, participants who received an HIV risk reduction intervention improved condom use at short-term, intermediate, and long-term assessments; change was better among men who have sex with men and people already infected with HIV, and when interventions provided intensive content across multiple sessions. Intervention participants reduced their number of sexual partners in interventions with intensive interpersonal skills training and in younger samples, especially at delayed intervals.

CONCLUSIONS

Sexual risk reduction interventions for African Americans increased condom use without increasing the number of sexual partners. Translating these interventions and further enhancing them continue as a high priority.

African-American women's exclusion of women and inclusion of kin and males into their social networks: a mistrust of women issue?

In a previous study, a small group of rural African American women were found to have negative attitudes of mistrust of women, which influenced the size and composition of their social network. The purpose of this study was twofold: (1) to describe the size, gender, and kin composition of the social network of a larger sample of rural and small-city African American women and (2) to psychometrically evaluate the Brown Attitude toward Women (BATW) scale. Two hundred rural and small town women (both drug users and non-users) completed a paper and pencil survey. A large percentage (from 44-75%) of women completing the survey held negative attitudes toward other women, which were reasons they gave for excluding women from their social networks. The women's mistrust of other women appears to contribute to their small network size. Women with smaller social networks tended to include a larger percentage of males and kin within their networks. Research and clinical implications of this phenomenon are discussed.

Perceptions of HIV risks and prevention strategies by rural and small city African Americans who use cocaine: views from the inside

HIV/AIDS disproportionately affects African Americans, yet knowledge gaps exist regarding their views of risks and effective prevention strategies. This focus group study of rural and small city African Americans who use drugs sought to assess these perceptions. Common views of HIV risks included drug use, physical appearance as an indicator of HIV status, intentional transmission, having multiple partners, unprotected sex, bisexuality, and unfounded trust. Trading sex for drugs and unprotected sex when high were seen as drug use/HIV risk links, while HIV education and condom use were identified as ways to decrease risk. Perceptions of effective strategies included community-based programs, gender specific groups, providing food or other incentives, and making the program fun. Healthcare professionals and parents were viewed as the best people to promote HIV prevention. Based on the findings, effective intervention for this target group should encompass ethnocentric community-based strategies that focus on HIV education, condom use skills, and drug risk reduction.

"A 28-day program ain't helping the crack smoker"--perceptions of effective drug abuse prevention interventions by north central Florida African Americans who use cocaine

CONTEXT

Cocaine is a major problem in the rural South, but knowledge is limited regarding the impact on African American populations.

PURPOSE

This study of 18-39-year-old black drug users assessed perceptions of contributing factors to drug use and possible interventions.

METHODS

The study design was qualitative-descriptive, utilizing 4 focus groups with 5 rural women and 14 small-city residents.

FINDINGS

Some respondents perceived that drug use initiation and continuation were due to themes of (1) loss, (2) peer pressure, (3) personal problems and dealing with pain, (4) desire for fun or to "feel good," and (5) drugs and drug-related messages within their environments. Common themes of effective strategies to stop drug use were (1) the necessity of wanting to quit, (2) the importance of help or support from family and friends, and (3) the need for resources, such as a job, car, and housing. Some respondents agreed on 3 human resources: (1) family, (2) ex-users, and (3) churches. Strategies to increase attendance at drug prevention programs included (1) making the program fun/enjoyable, (2) having mixed gender programs, (3) providing food/money, and (4) having the programs in their community. Recurrent themes were the lack of drug prevention intervention programs available to respondents and the failure of traditional programs of the majority culture to adequately meet their needs.

CONCLUSION

Effective drug prevention programs for southern African Americans who use cocaine must be community based, personalized, and culturally relevant.

Racial/ethnic disparities in the HIV and substance abuse epidemics: communities responding to the need

In 1998, community leaders prompted members of the Black and Hispanic Congressional Caucuses to urge President Clinton to declare HIV/AIDS a crisis in the African American and Latino communities; their advocacy resulted in the formation of the Minority AIDS Initiative. As part of this initiative, the Center for Substance Abuse Prevention (CSAP) of the Substance Abuse and Mental Health Services Agency funded the Substance Abuse and HIV Prevention Youth and Women of Color Initiative (CSAP Initiative). The CSAP Initiative is the first major federal effort to develop community-based integrated HIV and substance abuse prevention approaches targeting racial/ethnic populations that have been disproportionately impacted by HIV/AIDS. This article describes the current state of HIV prevention research involving racial/ethnic minority populations and the current status of the CSAP Initiative. The data collected through the CSAP Initiative, implemented by 47 community organizations, will help to fill the existing knowledge gap about how to best prevent HIV in these communities. This data collection effort is an unparalleled opportunity to learn about risk and protective factors, including contextual factors, that are critical to the prevention of HIV/AIDS in African American, Latino, and other racial/ethnic minority communities but that are often not investigated.

An analysis of substance use among adolescents from smaller places

This study examined trends in substance use among 12th grade students who live in smaller places. Subjects from smaller places were defined as those residing in nonmetropolitan and metropolitan counties who reported growing up on a farm, in the country (i.e., living in an unincorporated rural area but not on a farm) or in a small town (i.e., living in a place with fewer than 50,000 residents that is not a suburb or located next to a larger place). Six types of smaller places were created from a cross-tabulation of nonmetropolitan-metropolitan status and where subjects reported growing up. Substance-use rates among 12th graders residing in these six types of smaller places from 1976 to 1997 at three-year intervals were compared, based on data available from the Monitoring the Future study. For past-year alcohol use, some differences were found by place, with farm youth showing the lowest rates. Large differences were exhibited for past-year marijuana use, both across nonmetropolitan-metropolitan status and across youth from farm, country and small-town locations within nonmetropolitan counties. Rates of past-year illicit drug use were essentially the same regardless of location. Overall, when significant differences were found, most revealed less use for the more rural location.

Racial/ethnic disparities in the HIV and substance abuse epidemics: communities responding to the need

In 1998, community leaders prompted members of the Black and Hispanic Congressional Caucuses to urge President Clinton to declare HIV/AIDS a crisis in the African American and Latino communities; their advocacy resulted in the formation of the Minority AIDS Initiative. As part of this initiative, the Center for Substance Abuse Prevention (CSAP) of the Substance Abuse and Mental Health Services Agency funded the Substance Abuse and HIV Prevention Youth and Women of Color Initiative (CSAP Initiative). The CSAP Initiative is the first major federal effort to develop community-based integrated HIV and substance abuse prevention approaches targeting racial/ethnic populations that have been disproportionately impacted by HIV/AIDS. This article describes the current state of HIV prevention research involving racial/ethnic minority populations and the current status of the CSAP Initiative. The data collected through the CSAP Initiative, implemented by 47 community organizations, will help to fill the existing knowledge gap about how to best prevent HIV in these communities. This data collection effort is an unparalleled opportunity to learn about risk and protective factors, including contextual factors, that are critical to the prevention of HIV/AIDS in African American, Latino, and other racial/ethnic minority communities but that are often not investigated.

Crack cocaine use in rural migrant populations: living arrangements and social support

Correlates of crack cocaine use were studied among a targeted sample of migrant workers and their sexual partners (n = 571) in rural Southern Florida. Employment among men and recent drug-user treatment among men and women are positively related to crack use, as is involvement in crime and prostitution. Among women but not men, living with children is negatively related to crack use. Drug use and HIV prevention programs should intervene with individuals and their families and social groups. Migrant workers and their sexual partners also need effective drug-user treatment with long-term relapse prevention services.