Faculty Bibliography

OBJECTIVE:To examine HIV risk behavior and HIV infection among new initiates into illicit drug injection in New York City. DESIGN AND METHODS/METHODS:Cross-sectional surveys of injecting drug users (IDUs) recruited from a large detoxification treatment program (n=2489) and a street store-front research site (n=2630) in New York City from 1990 through 1996. Interviews covering demographics, drug use history, and HIV risk behavior were administered; serum samples were collected for HIV testing. Subjects were categorized into two groups of newer injectors: very recent initiates (just began injecting through 3 years) and recent initiates (injecting 4-6 years); and long-term injectors (injecting > or = 7 years). RESULTS:954 of 5119 (19%) of the study subjects were newer injectors, essentially all of whom had begun injecting after knowledge about AIDS was widespread among IDUs in the city. New injectors were more likely to be female and white than long-term injectors, and new injectors were more likely to have begun injecting at an older age (median age at first injection for very recent initiates, 27 years; median age at first injection for recent initiates, 25 years; compared with median age at first injection for long-term injectors, 17 years). The newer injectors generally matched the long-term injectors in frequencies of HIV risk behavior; no significant differences were found among these groups on four measures of injection risk behavior. HIV infection was substantial among the newer injectors: HIV prevalence was 11% among the very recent initiates and 18% among the recent initiates. Among the new injectors, African Americans, Hispanics, females, and men who engaged in male-male sex were more likely to be infected. CONCLUSIONS:The new injectors appear to have adopted the reduced risk injection practices of long-term injectors in the city. HIV infection among new injectors, however, must still be considered a considerable public health problem in New York City.

Drug injectors have simultaneously faced a devastating HIV I AIDS epidemic and an intense program of government repression and media demonization known as the "War on Drugs." We address patterns of association (networks) among drug injectors; how these networks shape their norms toward condom use and safer sex; the extent to which drug injectors take it upon themselves to promulgate safer sex norms to others; and, on a different level of analysis, the extent to which drug injectors have created organizations to reduce HIV transmission and to deal with other problems. Data from 767 street-recruited Brooklyn drug injectors indicate that about half of their drug- injector network ties, and of their sexual network ties, have lasted for at least five years; perceived peer norms supportive of condom use are widespread; almost half had told others (in the last month) that they should use condoms, and this was particularly likely among those in an ethnographically defined core group; consistent condom use with non-drug-injectors is reported for 44 percent of such relationships, and is most likely if the drug injector is HIV-infected, if the relationship is not *very close," if peer norms support condom use and among those without network ties to the ethnographic core group. Observational and historical research on drug users' organizations is used to describe the activities of "users' groups" around the world. In spite of the pressures they have been under, drug users' organizations exist in many cities and are active in anti-HIV efforts. Thus, norms and networks affect risk networks; and norms themselves vary by social network location and by social role. In spite of being subjected to intense repression and stigma, drug users have acted to shape their own culture, to protect themselves and others against HIV/AIDS and, to some extent, have engaged in collective action through formal organizations. The possibility of dialectic response seems to extend even to the most oppressed, dependent and stigmatized members of humanity.

Since sexual transmission of HIV among and from drug injectors is a frequent source of infection, condom use by them is important for prevention. This paper focuses on predictors of condom use at last sex by drug injectors with 'activated motivation,' that is, by those who already are trying to use condoms to reduce HIV risk. Principal subjects are 1,240 drug injectors who report activated motivation to use condoms to prevent HIV and who had had sex within 6 months before the interview. Many used condoms at last sexual event with primary partners (65%) and with casual partners (80%). Condom use with primary partners increased over time, and was higher among those who knew they were HIV-positive or who talked about AIDS with sexual partners, but was lower among those who knew they were HIV-negative, who were Black, Hispanic, women, younger, or high school graduates, or who used crack with their partners at the sexual event. Condom use with casual partners was lower among women, older drug injectors, and those who were high on alcohol along with their partners, and tended to be more likely among those who know they are infected. Condom use with both primary and casual partners was greater with partners who did not themselves inject drugs. Programs should urge drug injectors who are trying to use condoms to avoid HIV transmission that having sex while using psychoactive substances may be a barrier to their doing so even if they want to use condoms and have done so in the past. Finally, research should be conducted to determine if persons with activated motivation should receive HIV prevention assistance that is different from that offered those who lack risk-reduction motivation or those who want to reduce their risk behaviors, but have been unable to implement the desired changes