Sexual decision making and safer sex behavior among young female injection drug users and female partners of IDUs

Journal of Sex Research, Feb, 2003 by S. Marie Harvey, Sheryl Thorburn Bird, Christine Johnson De Rosa, Susanne B. Montgomery, Louise Ann Rohrbach

A current public health priority is strengthening women's ability to protect themselves from HIV and other sexually transmitted diseases (STDs) and to negotiate safer sex behaviors with their heterosexual partners. The number of AIDS cases among women has steadily increased (Centers for Disease Control and Prevention [CDC], 1999), and approximately half of all new cases occur in persons under the age of 25, with disproportionate numbers among young women and ethnic minorities (CDC, 2000). Since 1994, heterosexual transmission has been the most common mode of HIV transmission in women (CDC, 1999) and has accounted for 38% of all female AIDS cases reported in 2000 (CDC, 2000).

Through December 2000, at least 57% of all accumulated AIDS cases among women were attributed either to their own injection drug use (IDU; 41%) or to sex with an IDU partner (16%), compared with only 24% due to either of these exposures among men (CDC, 2000). Young women who inject drugs may be at even higher risk than males for a number of reasons. Female injection drug users (IDUs) are more likely than males to also have a sex partner who injects (Booth, 1995; Davies, Dominy, Peters, & Richardson, 1996), with needle sharing and sexual risk taking co-occurring (Baker, Kochan, Dixon, Wodak, & Heather, 1994; Booth, 1995). Female IDUs also have higher overall levels of sexual risk taking including having sex with three or more partners, exchanging sex for money or drugs, or having a partner who injects drugs or has sex with males (Sly, Quadagno, Harrison, Eberstein, & Riehman, 1997). Thus, young IDU women or women who have an IDU sex partner are considered to be at potentially high risk for HIV due to both their sexual and their drug-related risk behaviors.

Moreover, young people who are not in school and are homeless and/or who are involved in the street economy are known to have higher levels of IDU compared with their peers (1.5-2% vs. 5-39%; Johnston, O'Malley, & Bachman, 2000; Kipke, O'Connor, Palmer, & MacKenzie, 1995). In addition, compared with IDUs who begin injecting at an older age, IDUs who initiate use during adolescence show an overall higher drug risk profile (Battjes, Leukefeld, & Pickens, 1992), engage in more high risk sexual behaviors (Nelson, Vlahov, Solomon, Cohn, & Munoz, 1995), and are more vulnerable to HIV, Hepatitis C, other STDs, and infectious diseases (Bailey, Camlin, & Ennett, 1998; Clements, Gleghorn, Garcia, Katz, & Marx, 1997; DeMatteo et al., 1999; Ennett, Federman, Bailey, Ringwalt, & Hubbart, 1999; Kipke, Montgomery, Simon, Unger, & Johnson, 1997).

Finally, engaging in unprotected sexual intercourse puts women at risk not only for STDs including HIV but also for unintended pregnancy. Despite the availability of highly effective methods of contraception, almost a third (30.8%) of births and one half of pregnancies in the United States are unintended (Henshaw, 1998). Pregnancies among adolescents and young women ages 20 to 24 are particularly likely to be described as unintended (Brown & Eisenberg, 1995). Moreover, the realities of street life--including substance abuse, poor access to health care, food, and shelter, and basic hygienic and personal security needs--put female street youth at increased risk of unintended pregnancies (Ensign & Santelli, 1998; Green, Ennett, & Ringwalt, 1999; Green & Ringwalt, 1998; Noell, Rhode, & Ochs, 1997) and the serious negative consequences associated with these pregnancies (Brown & Eisenberg, 1995). Despite these trends, few studies have been conducted among young injection-drag-using populations, especially those that are street involved, and in the existing studies young women tend to be underrepresented.

In the absence of an effective vaccine or cure for AIDS, efforts to reduce the risk of HIV infection among women have focused on behavioral risk reduction. However, to design effective interventions for women, more empirical research is needed to understand what factors influence women's safer sex behavior. Despite the growing proportion of HIV infections among women that are due to heterosexual exposure, until recently much of the theory and research on HIV behavior change has been individualistic in conceptualization, often ignoring the social and cultural context of women's sexual behaviors (Amaro, 1995; Amaro & Raj, 2000; Wingood & DiClemente, 2000). These theories, such as the health belief model (Becker, 1974), theory of reasoned action (Azjen & Fishbein, 1977), social cognitive theory (Bandura, 1994), transtheoretical stages of change model (Prochaska & DiClemente, 1983, 1984), and AIDS risk reduction model (Catania, Kegeles, & Coates, 1992), assume that the individual has total control over behavior and do not address the diverse contextual factors related to gender (e.g., power differentials, gender roles, relationship types) that likely influence sexual behavior (Amaro, 1995). Unlike other risky behaviors such as smoking, drinking, and drag use, the transmission of HIV through sexual intercourse involves an interaction with another person. In addition, broader socio-cultural factors such as inequities in pay, discrimination based on gender, and inequalities in heterosexual relationships contribute to a set of life conditions that could greatly impact a woman's risk for HIV (Amaro, 1995; Amaro & Raj, 2000; Wingood & DiClemente, 2000). Consensus is mounting among theorists and researchers that HIV risk in women must be seen within the larger context in which women live. According to Amaro (1995, p. 445), "risk of HIV infection in women cannot be separated from the unequal status of women in American society and the resulting differences in power between men and women."