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

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in the United States was directed toward urgent issues of identifying and enumerating “risk groups,” transmission routes, risk behaviors, and HIV outcomes. Public health urgency, researchers’ familiarity and comfort with quantitative methodology, and a lack of basic information on the disease combined to create an atmosphere in which contextual issues received relatively little attention. While enumeration of risk behaviors is important for understanding the extent of the epidemic, assessing the potential for spread, and targeting prevention efforts, such efforts do not adequately clarify processes underlying initiation and continuation of risk, recovery from risk, and relapse to risk. Alternately, a focus on enumeration does not elucidate the temporal and situational variability in risk behaviors. In sum, simply counting risk behaviors does not adequately inform development of prevention activities. A CONTEXTUAL PERSPECTIVE MUST CONSIDER MULTIPLE FACTORS THAT IMPINGE ON RISK HIV risk behaviors are complex and cannot be adequately described by focusing on enumeration of behaviors and groups at risk. A shift in perspective is needed. This shift would move research from a primary focus on individual factors toward a contextual perspective that fully considers social and other environmental factors that impinge on risk decisions. Risk behaviors are integrally tied to basic physiological, social, and emotional functions of humans and are multiply determined. A contextual perspective demands consideration of familial structure and function, peer groups’ structures and processes, relationships with sex partners, relationships with drug-using partners, and the effects of drug use. Beyond these individual and small group levels, contextual perspectives require consideration of broader community factors such as economic conditions, access to employment, needle availability, and similar factors that impinge on and interact with interpersonal ones. It is clear that to understand the context of HIV risk behaviors related to the abuse of drugs, one must understand the epidemiology and natural history of drug abuse itself. HIV risk is imposed upon and incorporated into a larger context, and answers to questions about the temporal variance of drug abuse, the natural history of drug abuse, norms among 237
abusers, and other variables are needed to aid in developing specific hypotheses for study. Understanding of the many factors involved will require sophisticated skills in management and analysis of data collected from multiple sources. Univariate analyses that cannot account for interactions and shared variance among variables are not likely to provide significant advances in information. Understanding of family interactions and structures, of dyadic and sexual interactions, and of drug-using and nonusing social networks must be combined with an understanding of individual factors to clarify how risk behaviors are developed and maintained. Further, broad social factors beyond an individual’s control, such as economic conditions and needle or drug availability in the community, must be evaluated for their interactive effects with other determinants of risk. Such multifaceted studies will require sophisticated quantitative and qualitative methods. RESEARCH ON CONTEXT OF HIV RISK MUST BE GUIDED BY RELEVANT THEORETICAL UNDERSTANDINGS OF BEHAVIOR AND DISEASE Review participants noted that research on risk context has not been adequately guided by theory. This is especially unfortunate because epidemiological patterns tend to recur in drug abuse, and it is possible to use past experience and general theories to guide research. For example, patterns of drug use seen in the crack epidemic are being repeated as the use of methamphetamine rises. Similarly, patterns of sexual behavior associated with crack use may be seen in methamphetamine users. Theoretical perspectives (e.g., social learning theory) have been used to plan intervention and prevention programs, but these perspectives have been less utilized to develop understanding of risk. Theory-based research on risk behaviors is difficult to develop and conduct because of the needs to operationalize relevant constructs and to specify relationships of constructs to behaviors. In many cases, theory must be developed in conjunction with the collection of data on risk behaviors, so theory development, theory validation, and understanding of context will occur in a dynamic, reciprocal relationship. Certainly studies that can validate theoretical predictions have merit, but in many cases specific predictions must await data to help develop the theoretical framework. In cases when theory validation is not possible, to be guided by theory means that 238
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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.
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comprise 23 percent of all adolesce
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232 (18 percent) of the cases; and
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Although these data provide an over
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Most of these were unprotected sexu
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national epidemiologic survey of hi
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Hawkins et al. 1992; Newcomb et al.
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higher rates of HIV/AIDS in adolesc
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Boyer, C.B. Psychosocial, behaviora
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Irwin, C.E., Jr., and Shafer, M.A.
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Zweig Greenberg, MS.; Singh, T.; Ht
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the types of intervention strategie
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from a study group of 52 youths who
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forearm during a sexual episode. At
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I was nice looking, like I can do a
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It is unclear whether the disinhibi
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continual sexual dysfunction was re
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TWEAKING, FREAKING, AND OVER-AMPING
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highway of love. It’s like, I’d
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Unprotected sexual activity is more
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alternatives and opportunities, and
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the night and food for the morning.
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7. also can help youths explore and
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Jessor, R., and Jessor, S.L. Proble
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AUTHORS Mary Jane Rotheram-Borus, P
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Brunswick goes on to discuss the le
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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: Future Directions for Studies on th
Page 245 and 246: Behavior patterns can be clarified
Page 247 and 248: As Des Jarlais noted, designs and a
Page 249 and 250: strengths within a setting or indiv
Page 251 and 252: National Institute on While limited
Page 253 and 254: 62 NEUROSCIENCE METHODS IN DRUG ABU
Page 255 and 256: 89 BIOLOGICAL VULNERABILITY TO DRUG
Page 257 and 258: 111 MOLECULAR APPROACHES TO DRUG AB
Page 259 and 260: 127 PROGRESS AND ISSUES IN CASE MAN
Page 261: NIH Publication No. 94-3750 Printed
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The Context of HIV Risk Among Drug Users and Their Sexual Partners

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