Condom Use Among Male Injecting-Drug Users -- New York City, 1987-1990

Heterosexual transmission of human immunodeficiency virus (HIV) continues to increase, especially among injecting-drug users (IDUs) and their sex partners (1). During 1991, 22% of women with acquired immunodeficiency syndrome (AIDS) in the United States reported having had sex with a male IDU; this risk behavior was second to injecting-drug use (48%) as a transmission category for women. To better understand how to reduce heterosexual transmission of HIV, a study on condom use among male IDUs on the Lower East Side of Manhattan, New York City, was conducted as part of CDC AIDS Community Demonstration Projects (2). This report summarizes the results of that study.

From August 1987 through October 1990, 450 male IDUs were recruited to participate in the study by trained former IDU outreach workers operating from a research storefront located in the community. Participants were offered on-site confidential HIV counseling and antibody testing and were paid $20 per interview. Referrals for a variety of medical and social services were provided, including referral for drug abuse treatment, and participants were given "AIDS prevention kits" (i.e., bleach, a clean bottle cap, cotton and water, condoms, and AIDS pamphlets, including text and illustrated instructions about using condoms and cleaning needles).

Participants were asked about their injecting-drug behaviors, number of steady and casual sex partners, and frequency of condom use during the "typical" month of the year before interview.

Most (297 (66%)) participants reported having injected drugs for 14 or more years; 240 (53%) were aged 30-39 years, and 332 (74%) had less than a high school education. Participants were evenly distributed across racial/ethnic categories: white, 37%; black, 32%; and Hispanic, 31%. Nearly all participants (438 (97%)) reported sexual contact only with women. More than one third (165 (37%)) of participants consented to HIV testing; 85 (52%) were HIV seropositive.

Most (348 (77%)) male IDUs reported having "steady" female sex partners, 21 (5%) reported only "casual" partners, and 81 (18%) reported having both "steady" and "casual" partners (Table 1). The largest percentage of respondents (193 (43%)) reported never using condoms, 139 (31%) reported always using condoms, and 118 (26%) reported using condoms some of the time. Participants with both steady and casual sex partners were more likely to use condoms "some of the time" than were those with only steady or only casual sex partners. Among participants with both types of partners, using a condom all the time was more common with casual (58 (72%)) than with steady (24 (30%)) partners.

Individual condom use was strongly associated with having peers who engaged in some type of sexual risk reduction (i.e., condom use or restriction to safer sexual activities) (Table 1). Condom use was also associated with drug-injection HIV risk reduction (i.e., cleaning needles or restriction to new needles) (Table 1).

Reported by: S Tross, PhD, A Abdul-Quader, PhD, H Silvert, PhD, National Development and Research Institutes, Inc. D Des Jarlais, PhD, Beth Israel Medical Center, New York City. Behavioral and Prevention Research Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Because a substantial proportion (43%) of IDUs described in this report did not use condoms, the promotion of consistent condom use in this population remains an urgent priority for preventing sexual transmission of HIV. Findings from this study suggest the greater amenability of this population to risk reduction (i.e., sometimes using condoms) rather than risk elimination (abstinence or mutual monogamy among persons without HIV or other sexually transmitted diseases).

Despite a slightly higher percentage of white participants, the sample composition of this study is similar to those of other studies of IDUs in New York City. However, the findings in this report are subject to two limitations. First, because data were obtained from IDUs who volunteered for the program, findings cannot be generalized to IDUs unwilling or unable to participate. Second, the report includes male IDUs in a limited area, Manhattan, New York City, where HIV prevalence in IDUs has been 55% or higher for many years (3). Thus, these findings may not reflect HIV risk-reduction behaviors among at-risk groups in other locations.

The identification of barriers and promoters to consistent condom use has three direct implications for the development of content and methods for preventing sexual transmission of HIV among IDUs. First, among men with both steady and casual sex partners, lower rates of consistent condom use were observed with steady partners than with casual partners. The finding of lower rates of condom use within rather than outside a primary relationship has been reported in other studies of HIV sexual behavior both in IDUs (4) and in homosexual men (5). This suggests that condom use messages should target sexual behavior within primary relationships where partners do not know their HIV status, are discordant for HIV infection, or one or more partners are continuing activities that pose a risk for HIV infection (e.g., needle sharing and multiple sex partners).

Second, higher rates of consistent condom use were observed among men whose peers were also practicing safer sex. Previous studies have documented a positive effect of peer support on HIV risk-reduction behavior in both IDUs (4) and in homosexual men (6). This suggests that HIV-prevention programs should use peer outreach and group methods to maximize the impact of social influence on this behavior.

Finally, higher rates of consistent condom use were observed among men who were also practicing safer drug-injecting behaviors, indicating the need to develop comprehensive messages that link both drug injection-related and sexual modes of HIV prevention. Findings from this study are being used to guide community-level intervention projects in Denver; Long Beach, California; and New York City that target IDUs and their sex partners (2,7).

References

1. CDC. HIV/AIDS surveillance report. Atlanta: US Department of Health and Human Services, Public Health Service, January 1992.

2. CDC. NCPS AIDS Community Demonstration Projects: what have we learned, 1985-1990. Atlanta: US Department of Health and Human Services, Public Health Service, June 1992.

3. Des Jarlais DC, Friedman SR, Novick DM, et al. HIV-1 infection among intraveneous drug users in Manhattan, New York City, from 1977 through 1987. JAMA 1989;261:1008-12.

4. Abdul-Quader AS, Tross S, Friedman SR, et al. Street-recruited intravenous drug users and sexual risk reduction in New York City. AIDS 1990;4:1075-9.

5. Stall RD, Coates TJ, Hoff C. Behavioral risk reduction for HIV infection among gay and bisexual men: a review of results from the United States. Am Psychol 1988;43:878-85.

6. Joseph JG, Montgomery SB, Emmons CA, et al. Perceived risk of AIDS: assessing the behavioral and psychological consequences in a cohort of gay men. Journal of Applied Social Psychology 1987;17:231-50.

7. O'Reilly KR, Higgins DL. AIDS community demonstration projects for HIV prevention among hard-to-reach groups. Public Health Rep 1991;106:714-20.

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