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

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Bringing the Context in From the Cold: Substantive, Technical, and Statistical Issues for AIDS Research in the Second Decade Ann F. Brunswick This chapter discusses an ecological model of health that has guided the author’s research for 25 years. Its articulation is derived from Bronfenbrenner’s (1979) paradigm of behavioral influences. The idea of applying a behavioral model to guide conceptualizations about an illness follows from a cross-fertilization of social psychology and health. This model is particularly apt for studying illnesses incurred through human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), which undeniably have strong behavioral linkages. The behavioral underpinning refers not only to understanding that contagion comes about through specific behaviors, but also to the behavioral responses HIV exacts at multiple social levels and the crosscurrents of social response it has evoked at different social levels. Following from table 1, which summarizes the model discussed here, these include: moral (macrosystem), legal and institutional (exosystem), interpersonal (microsystem), and individual knowledge, belief, and attitudes (ontogenic or intrapersonal system) (Brunswick 1985). The ecological model is a reminder of what needs to be considered when attempting to bring the context in from the cold. It bridges the spheres of interest of different social science disciplines: political science, anthropology, social psychology, and sociology. The model provides a heuristic device for conceptualizing the nature of the epidemic(s) and identifying how HIV infection is experienced differently by low-income people of color, as compared to the experience of the mostly middle-class gay community on whom earlier scientific findings were based. This basic ecological paradigm serves as a guide to variables to be included in HIV/AIDS studies and identifies some measurement pitfalls to avoid in the context of injection drug users (IDUs). The need for a contextual approach in HIV-related research, policies, and programs is underscored by the fact that HIV-related disease is not randomly distributed, either geographically or socially, nor does symptom 187
conversion and perhaps even seroconversion occur pari passu among all who are exposed (Brunswick et al., forthcoming). It is easier to give lip service to the social nature of the disease and to the need for incorporating different social levels into its analysis than to do so. The most frequently tested research model in AIDS prevention research is the health belief model (HBM). Yet the HBM is of questionable validity when applied to IDU and minority populations because of its predominantly cognitive dimensions of cost-benefit and vulnerability appraisals, behavioral and outcome efficacy, and because the model operates primarily if not solely in the ontogenic (within the individual) sphere (Brunswick and Banaszak-Holl, unpublished data). A major architect of the HBM movement recently has critiqued the current health promotion movement in words that are equally applicable to the neglect of the social context in HIV research, policy, and programs: Finally, I turn to what, in my estimation, is the most disturbing aspect of the contemporary health promotion movement: its tendency to locate the responsibility for the cause and the cure of health problems in the individual. Three assumptions appear to underlie this approach: personal health-related behaviors are discrete and independently modifiable; anyone can decide to alter his/her behavior and then go on to do so successfully; and everyone has a personal responsibility to ‘live well’ through self-discipline and behavior modification.... These assumptions do not fit very well with what we know about the major determinants of health and the prevention of illness. I would argue, first, that health habits are acquired within social groups (i.e., family, peers, the subculture).... The lifestyle approach enables us to ignore the more difficult, but at least equally important, problem of the social environment which both creates some lifestyles and inhibits the initiation and/or maintenance of others (Becker 1993, p. 3-4). The three areas identified in this chapter’s title are discussed in the remainder of the chapter: substantive, technical, and statistical issues that might be helpful in rethinking existing research models and methods for studying HIV. They are guided by the ecological model and concern for situational and environmental factors that have been articulated above. 188
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National Institute on Drug Abuse RE
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ACKNOWLEDGMENT This monograph is ba
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Drug Use and HIV Risk Among Male Se
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Partners. The review was held April
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Inciardi, J.A.; Lockwood, D.; and P
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highlights the critical importance
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AUTHOR Richard H. Needle, Ph.D., M.
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Blower and colleagues (1991) have p
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Even in areas with low seroprevalen
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involves using a syringe to draw bl
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Hispanics were less likely to repor
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victimization through theft, violen
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sharing? When are needles deliberat
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Chitwood, D.D.; McCoy, C.B.; Inciar
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Page, J.B.; Smith, P.C.; and Kane,
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HIV/AIDS Risks Among Male, Heterose
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during that time, and the possibili
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All of these issues and considerati
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ecoming the norm for both male and
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the skin on his penis while having
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REFERENCES Ball, J.C., and Chambers
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Johnson, A.M.; Petherick, A.; David
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Vogt, M.W.; Craven, D.E.; Crawford,
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transmission from males to females
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(this volume), there is little atte
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Clayton, R.; Voss, H.; Robbins, C.;
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Female Drug Abusers and the Context
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have the data but interpret it supe
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important to examine current studie
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found in this study was low socioec
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who trade sex for crack; and simila
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esponsibilities in perspective. Suc
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Robles and colleagues (1990) examin
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The lack of rational thought separa
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Factors Associated With Sexual Risk
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Factors Associated With Poverty A n
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encouraging such women to leave the
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Hispanic women but extramarital aff
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coherence—the sense that life is
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the change agent may be a crucial f
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Centers for Disease Control and Pre
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Jemmott, J.B.; Jemmott, L.S.; Spear
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O’Leary, A.; Celentano, D.; Maiba
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Drug Use and HIV Risk Among Gay and
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with 34.6 percent of gay men and 28
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found among both hustlers and call
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Substance Use and HIV-Transmitting
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TABLE 1. Prevalence of substance us
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less than 2 percent of participants
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TABLE 2. Quantity of alcohol use am
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A fourth study of gay/bisexual men,
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in mind, however, that most of the
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seropositivity and reported NMPD us
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interaction and education than men
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Geographic differences found in the
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that they are intending or desirous
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enough is known in general about th
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REFERENCES Calzavara, L.M.; Coates,
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Ostrow, D.G.; Beltran, E.; Chmiel,
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Drug Use and HIV Risk Among Male Se
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prostitutes were HIV positive, as c
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Trade hustlers are usually heterose
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TABLE 1. Number of Completed Interv
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diagnosed slightly more often than
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TABLE 2. Injection Drug Use by Type
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By the 100th interview, the screeni
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SUMMARY AND CONCLUSIONS In general,
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Plant, M. Sex work, alcohol, drugs
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HIV Risk in Drug-Using Adolescents
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AUTHOR Vincent L. Smeriglio, Ph.D.
Page 141 and 142: comprise 23 percent of all adolesce
Page 143 and 144: 232 (18 percent) of the cases; and
Page 145 and 146: Although these data provide an over
Page 147 and 148: Most of these were unprotected sexu
Page 149 and 150: national epidemiologic survey of hi
Page 151 and 152: Hawkins et al. 1992; Newcomb et al.
Page 153 and 154: higher rates of HIV/AIDS in adolesc
Page 155 and 156: Boyer, C.B. Psychosocial, behaviora
Page 157 and 158: Irwin, C.E., Jr., and Shafer, M.A.
Page 159 and 160: Zweig Greenberg, MS.; Singh, T.; Ht
Page 161 and 162: the types of intervention strategie
Page 163 and 164: from a study group of 52 youths who
Page 165 and 166: forearm during a sexual episode. At
Page 167 and 168: I was nice looking, like I can do a
Page 169 and 170: It is unclear whether the disinhibi
Page 171 and 172: continual sexual dysfunction was re
Page 173 and 174: TWEAKING, FREAKING, AND OVER-AMPING
Page 175 and 176: highway of love. It’s like, I’d
Page 177 and 178: Unprotected sexual activity is more
Page 179 and 180: alternatives and opportunities, and
Page 181 and 182: the night and food for the morning.
Page 183 and 184: 7. also can help youths explore and
Page 185 and 186: Jessor, R., and Jessor, S.L. Proble
Page 187 and 188: AUTHORS Mary Jane Rotheram-Borus, P
Page 189 and 190: Brunswick goes on to discuss the le
Page 191: permission-giving introductions to
Page 195 and 196: TABLE 1. Ecological paradigm of con
Page 197 and 198: TECHNICAL ISSUES Technical issues i
Page 199 and 200: eliability. It seems obvious that q
Page 201 and 202: sometimes as many as three zip code
Page 203 and 204: Resources and effort are required t
Page 205 and 206: Brunswick, A.F.; Lewis, C.S.; and M
Page 207 and 208: The Context of Risk: Ethnographic C
Page 209 and 210: same meaning may be extended to dru
Page 211 and 212: THE CONTEXT OF RISK Context is an a
Page 213 and 214: hurried, and adequate needle cleani
Page 215 and 216: degrading sexual acts, poignantly m
Page 217 and 218: searched me and I had stashed the c
Page 219 and 220: REFERENCES Agar, M. The Professiona
Page 221 and 222: Ouellet, L. J.; Jimenez, A.D.; John
Page 223 and 224: Assessing the Reliability and Valid
Page 225 and 226: TABLE 1. Sociodemographic profile o
Page 227 and 228: Table 2 shows percentage agreement
Page 229 and 230: FORENSIC TECHNIQUES TO DOCUMENT SEL
Page 231 and 232: cross-tabulated with dichotomous me
Page 233 and 234: TABLE 6. Relationship of question t
Page 235 and 236: aggravate self-presentation bias. T
Page 237 and 238: TABLE 8. Percent of subjects report
Page 239 and 240: intercourse, and since anal interco
Page 241 and 242: Future Directions for Studies on th
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abusers, and other variables are ne
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Behavior patterns can be clarified
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As Des Jarlais noted, designs and a
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strengths within a setting or indiv
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National Institute on While limited
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62 NEUROSCIENCE METHODS IN DRUG ABU
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89 BIOLOGICAL VULNERABILITY TO DRUG
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111 MOLECULAR APPROACHES TO DRUG AB
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127 PROGRESS AND ISSUES IN CASE MAN
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NIH Publication No. 94-3750 Printed
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