The Context of HIV Risk Among Drug Users and Their Sexual Partners

enough is known in general about these associations and their real risk of
propagating new waves of HIV infection among subpopulations of
gay/bisexual men, descriptive ethnographic studies among target
populations—in advance of or coincidental with the start of intervention
activities—are needed to increase the likelihood of beneficial outcomes.
This applies especially to those subpopulations of men who have sex with
men and who are particularly at risk of engaging in HIV-transmitting
sexual behaviors: antisocial risk takers; gay youth (especially street
youth and hustlers); high school dropouts; minority men who are not gay
self-identified; and men of lower socioeconomic background. The
consistent finding that significant proportions of HIV-transmitting sexual
behaviors among some specific populations are associated with NMPD
use argues for vigorous attempts at targeted intervention programs with
those populations.
Given the well-documented efficacy of community-based interventions
that use either cognitive-behavioral techniques within small groups
(Kelly et al. 1989) or community leadership norm-changing and
dissemination (Kelly et al. 1991b, 1992), it seems appropriate to examine
whether a combination of these approaches might be useful. While small
group interventions are effective in helping individuals to recognize the
behavioral patterns, including NMPD use, that place them at risk for
lapse to unprotected sexual behavior, the skills for negotiating safer sex
learned in such group interventions are frequently insufficient to prevent
lapse when alcohol or NMPD use is involved. On the other hand,
changing community norms about NMPD use through opinion leader
interventions and social marketing techniques may help at-risk
individuals avoid using substances or alter their use patterns to avoid
them in sexual encounters.
The author recommends development of community-based interventions
that combine knowledge about recreational drug use and sexual behavior
interventions into effective programs to target this specific aspect of HIV
prevention. Such interventions would explicitly acknowledge the links
between recreational substance use and high-risk sexual behavior, while
accepting the fact that there are no simple answers or explanations for
those links.
Alternative intervention approaches may be needed for specific at-risk
populations. For example, minority men who are not self-identified as
gay or bisexual are unlikely to be reached through gay community-based
media or social organizations. However, through preliminary
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