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

transmission from males to females than the reverse in the United States
and Europe (European Study Group 1992; Vermund et al. 1990). Apart
from female IDUs, other sexual partners of IDUs comprise a large
heterogenous population in which cultural, social, racial, and other factors
are major determinants of sexual risk behavior and safer sex practices.
Since there has been very little recent research on female IDUs, a brief
review of the literature on women who inject drugs that predates the HIV
epidemic is included in this introduction. The injection method has been
employed nearly universally by opiate addicts since the 1940s (Brecher
1972), with cocaine a more recent but important drug of injection since
the 1970s (Kozel and Adams 1986). Regardless of the type of drug
injected, the estimate of the ratio of male to female IDUs (Brown and
Weissman 1994; Cohen et al. 1988; Turner et al. 1989) and “hard” drug
users is 3 to 1 (Cottler et al. 1990). This ratio persists in current statistics
derived from needle exchange programs (University of California 1993).
The lower ratio of female to male IDUs has been attributed to a number
of factors: greater stigmatization and thus secrecy of women who use
illicit drugs (Barnard 1993; Kane 1991; Rosenbaum 1988); faster
removal of women from the active injecting population through treatment
or abstinence as compared to men (Hser et al. 1987; Longshore et al.
1993; Rosenbaum 1981); and reduced opportunity to initiate and sustain
hard drug use among women with resultant irregular or polydrug use
patterns (Rosenbaum 1981; Worth 1991).
There is some indication of a trend toward convergence for males and
females in population-based (i.e., not samples of IDUs alone) drug use
studies (Clayton et al. 1986). Population-based surveys show few
differences by gender among adolescents (Kaestner et al. 1986). A
community-based life study of drug use and health care behavior that has
followed Harlem adolescents for many years also shows only a small
excess of injection drug use by males compared to females since 1978
(11 percent versus 9 percent) (Brunswick et al. 1986).
Whether due to biased sampling, location-specific patterns, or an age
cohort phenomenon, gender-based differences remain among the most
severely affected drug users (Johnson 1986). The 3 to 1 gender ratio in
IDU samples most likely is the result of social factors that have a
relatively greater impact on women than men at each stage in the course
of becoming addicted. This differential dropout likely results in an IDU
population with more severely affected women compared to men.
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