Sexual and drug use behaviors among female crack users: a multi-site sample
Introduction
Crack use and sex exchange have been identified as co-factors for the risk of HIV, especially for women (Inciardi, 1993 Inciardi et al., 1993 Inciardi, 1994 CDC, 1995, Inciardi, 1995 Holmberg, 1996, Iguchi and Bux, 1997, Word and Bowser, 1997, Coyle, 1998, Tortu et al., 1998). One study, for example, found that female crack smokers were six times as likely as non-crack users to have had more than 20 sexual partners, 14 times more likely to sell sex, and four times as likely to have syphilis or other STDs, and female crack smokers who had never injected drugs were twice as likely to have HIV as noncrack smokers (Edlin et al., 1994). Another study found that crack users were four times more likely to exchange sex than opioid users (Cohen et al., 1994). Wallace et al. (1997) indicated that 24% of female crack users with no history of injection drugs HIV positive compared with 17% of women who did not smoke crack. Further, Tortu et al. (1998) found that sex exchange was predictive of HIV seropositivity.
Women involved in drug use have some striking similarities in their experiences once they begin heavy drug use (Inciardi et al., 1993). However, women who use drugs differ on at least one important variable: some women exchange sex for drugs and/or money and some do not. Thus, women drug users are differentially at risk for HIV. Women who exchange sex for drugs and/or money potentially put themselves at higher risk for contracting and transmitting the HIV/AIDS virus and other STDs. Chiasson et al. (1991) found that women who reported both sex exchange and crack use were more likely to be HIV positive than those who reported only one of these behaviors. In addition, because these drug-abusing women have frequent, unprotected sex with many different sex partners, they are at risk of becoming pregnant and thus, potentially exposing their fetus to the risk of contracting HIV and/or being drug addicted.
Amaro (1995) indicated that HIV prevention interventions fail to demonstrate HIV risk behavior change in the general female population. For female crack users, HIV prevention intervention may be more difficult to implement and less likely to effect change (Inciardi, 1993). The chaotic lifestyle of the crack user seems to dictate daily risks of overdosing and exposure to potentially violent situations each time they use drugs. In addition, sex exchange practice may be motivated by current economic and daily survival needs (Murphy and Rosenbaum, 1992). Thus, warning crack users and other drug users that needle sharing or unsafe sex may facilitate an infection that could cause death sometime in the near future may have very little impact (Inciardi, 1993).
Alternative approaches may be necessary to reach groups of high risk women such as crack users who engage in sex exchange practice. An intermediate step in HIV prevention is to examine behaviors of subgroups of high risk populations. Although there are several qualitative studies focused on women crack users who exchange sex for drugs or money, very little attention has been given to the behaviors and differences for subgroups of women crack users who exchange sex and those who do not exchange sex (Inciardi et al., 1993, Edlin et al., 1994). In fact, Tortu et al. (1994) analyzed the National AIDS Demonstration and Research (NADR) data for differential HIV risk behaviors for women and suggested that a next step in analysis was to discover which demographic and drug use variables differentiates group status for women who exchanged sex and women who did not exchange sex. Logan et al. (1998) recently examined sexual and drug use behaviors for women crack users in Kentucky who exchanged sex and women crack users who did not exchange sex and found that homelessness and criminal justice involvement were positively related to sex exchange. Also, women who had past substance abuse treatment were four times more likely to also report ever exchanging sex than women who did not have past treatment history. One limitation of the Logan et al. (1998) study was the limited sample (e.g. data included only one state and the overall number of subjects in the study was small). The current paper expands on the Logan et al. (1998) study by analyzing data collected from 20 US sites with a larger sample of female crack users. Specifically, the purpose of this paper was to compare demographic and HIV risk behaviors of female crack users who reported ever exchanging sex for drugs and/or money with female crack users who report never having exchanged sex for drugs and/or money from a multi-site sample in order to identify differences between these subgroups as an important intermediate step in facilitating the effectiveness of prevention interventions with female crack users.
Section snippets
Participants
The participants for this study were selected from an overall sample of 23 500 male and female drug users recruited into the NIDA Cooperative Agreement Project. The sample for this study consists of female crack users (n=4667) who entered the study between January, 1992 and July, 1997. Of the 4667 women crack users, 2658 (57%) reported exchanging sex for drugs and/or money and 2009 (43%) women reported never exchanging sex for drugs or money. Women represented 30% of the total number of
Demographic characteristics
Of the women who exchanged sex, 94% reported ever exchanging sex for money and 70% reported ever exchanging sex for drugs (see Table 1).
Women who exchanged sex differed on a number of demographic and background characteristics from women who did not exchange sex. Larger proportions of women who exchanged sex were African-American, homeless, and lived alone; and smaller proportions lived with a sex partner and/or had children under the age of 18 living with them than women who did not exchange
Logistic regression
Logistic regression was conducted to assess which variables were most predictive of sex exchange for crack users overall and then study sites were grouped according to region and predictor variables were assessed separately by region. The following five dichotomous predictor variables were included in the regression model: race/ethnicity (African-American or other), income less than $500, homelessness, ever in treatment or detox, and criminal justice involvement. The variables were entered into
Discussion and implications
The purpose of this paper was to compare women crack users who reported exchanging sex and women crack users who did not report exchanging sex from a multi-site sample, in order to identify factors that could facilitate the effectiveness of prevention interventions. Results indicated that women who exchanged sex and women who did not exchange sex were similar on only a few background variables. These results are different from an earlier study of women crack users and sex exchangers by Logan et
Acknowledgements
This study is supported by grant no. DA08154 from the National Institute on Drug Abuse. The authors would especially like to acknowledge Dennis Fisher, Robert Trotter, Sally Stevens, James Inicardi, Fen Rhodes, John Waters, Robert Booth, Merrill Singer, Jeffrey Hoffman, Clyde McCoy, Norman Weatherby, Vernon Shorty, Marcia Andersen, Linda Cottler, Sherry Deren, Wendee Wechsberg, Harvey Siegal, Michael Stark, Lynne Kotranski, Rafaela Robles, Isaac Montoya, David Desmond, and Richard Needle.
References (31)
The antecedents of women’s crack cocaine abuse: family substance abuse, sexual abuse, depression and illicit drug use
J. Subst. Abuse Treat.
(1993)- et al.
The association of physical and sexual abuse with HIV risk behaviors in adolescence and young adulthood: implications for public health
Child Abuse Neglect
(1994) Considering women’s realities in HIV prevention
Am. Psychol.
(1995)- Centers for Disease Control, 1995. Women and HIV/AIDS. HIV/AIDS...
- et al.
Heterosexual transmission of HIV-1 associated with the use of smokable freebase cocaine (crack)
AIDS
(1991) - et al.
High-risk behaviors for HIV: a comparison between crack-abusing and opioid-abusing African-American women
J. Psychoactive Drugs
(1994) - et al.
Quasi-experimentation: Design and Analysis Issues for Field Settings
(1979) Women’s drug use and HIV risk: findings from NIDA’s cooperative agreement for community-based outreach/intervention research program
- Coyle, S., 1993. The NIDA HIV counseling and education intervention model: Intervention manual. (NIH pub. No. 93-3508)....
- et al.
Reliability of drug users’ self- reported HIV risk behaviors and validity of self-reported recent drug use
Assessment
(1994)