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

hurried, and adequate needle cleaning is unlikely. Such immediate,
microlevel contextual elements often have a causal association with more
encompassing macrolevel social, economic, and political forces that
shape drug injectors’ lives.
CONTEXT AT THE MACROLEVEL
Several researchers have linked drug abuse, escalating violence, and the
overwhelmingly uneven distribution of HIV among inner-city minority
populations to fundamental changes in the American economy. They
contend that there is a causal link between the economic restructuring of
the American economy as characterized by corporate downsizing and
deindustrialization—the shift from manufacturing to information
processing and service—and the social pathology that seems endemic to
America’s inner cities. They argue that these structural changes have
been particularly detrimental to urban poor people and have resulted in
job loss, changing job requirements, increasing social isolation, and the
withdrawal of municipal services from inner-city neighborhoods (Jencks
1988; Massey 1990; Newman 1992; Phillips 1990; Wallace 1993; Wilson
1987). These conditions have become persistent and dominant forces in
the lives of urban poor people, and are manifested in myriad ways that
have direct public health implications.
The importance of considering these macrolevel, structural conditions in
epidemiological studies of HIV transmission is readily apparent when
considering the individuals who are most vulnerable. Increasingly, they
are impoverished people of color. As Page and colleagues suggest in the
introduction to an article about Miami drug injectors, “All of the
described hustles, theft and dating activities operate in a cultural
environment where hopelessness and poverty have been endemic for
decades” (Page et al. 1990, p. 63). For drug users, these conditions not
only contribute to their drug use; they also exacerbate the dangers
involved in using drugs.
Bourgois (1989a) anchored his study of Spanish Harlem and its
expanding underground, crack-based economy within the changing
economy of New York City and described how the shift from a
manufacturing-based economy to a service-based economy has affected
the lives of people who formerly found employment as workers in the
city’s factories. As he explains, “The underground economy beckons
seductively as the ultimate ‘equal opportunity employer.’ The rate of
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