HIV Risk Reduction Among African-American Women ... - Springer Link

P1: ZBU AIDS and Behavior (AIBE)

pp737-aibe-459290

February 24, 2003

9:32

Style file version June 22, 2002

C 2003) AIDS and Behavior, Vol. 7, No. 1, March 2003 (°

HIV Risk Reduction Among African-American Women Who Inject Drugs: A Randomized Controlled Trial Claire E. Sterk,1,4 Katherine P. Theall,1 Kirk W. Elifson,2 and Daniel Kidder3 Received Jan. 31, 2002; revised June 26, 2002; accepted Sep. 25, 2002

A community-based HIV intervention for African-American women who are active injection drug users (IDUs) was evaluated. Seventy-one women (aged 20–54 years) were randomly assigned to one of two enhanced gender- and culturally specific intervention conditions or to the NIDA standard condition. Substantial decreases ( p < .001) were found in the frequency of drug use and the frequency of drug injection as well as in the sharing of injection works or water and the number of injections. Trading sex for drugs or money, having sex while high, as well as other sexual risk behaviors were also reduced significantly. Furthermore, women in both enhanced intervention conditions were more likely to reduce their drug-using and sexual risk behaviors than were women in the standard condition. Results indicate the value of including additional components in interventions designed to reduce the risk of infection with HIV among women who inject drugs. KEY WORDS: Human immunodeficiency virus (HIV); women; crack cocaine; risk reduction; intervention.

INTRODUCTION

sure to be even higher, with 64% related to heterosexual contact and 33% to injection drug use (CDC, 2001). Reducing the HIV risk among female injection drug users (IDUs) will require that the women engage in safer drug injection and sexual behaviors. Consistent involvement in safer sex, in particular, is a behavior that is difficult to achieve (Booth et al., 2000; Cottler et al., 1998; Coyle, 1998; Needle et al., 1998; O’Leary, 1999). Research has found protective actions are often hindered by gender and sociocultural factors, including the social context in which injection drug use and sexual activity take place. In addition to the power imbalance in the women’s sexual relationships and the stressors of being a drug user, behavioral change often also is impacted by a woman’s level of knowledge, risk perception, skills, support, and ambivalence (Amaro, 1995; DiClemente and Wingood, 1995; Sterk, 1999; Wechsberg et al., 1998). HIV risk reduction prevention interventions need to be sensitive to all these issues in order to be effective. In many interventions among IDUs, much attention has been focused on reducing risky drug practices such as the sharing of syringes and other drug

Increasingly women are at risk for HIV infection and the cumulative number of AIDS cases among women in the United States continues to grow. The percentage of AIDS cases among U.S. women increased from 7% in 1986 to 26% in 2000 (Centers for Disease Control and Prevention [CDC], 2001). The rate of AIDS cases among U.S. women is highest among African-American women (46 per 100,000). The AIDS incidence reported among women in 2000 reveals heterosexual contact (38%) and injection drug use (25%) to be the main exposure categories. Estimated incidence diagnosed shows both rates of expo1 Emory

University, Rollins School of Public Health, Department of Behavioral Sciences and Health Education, Atlanta, GA. 2 Georgia State University, Department of Sociology, Atlanta, GA. 3 Opinion Research Corporation Company (ORC Macro), Atlanta, GA. 4 Correspondence and reprint requests should be directed to Claire E. Sterk, Emory University, Rollins School of Public Health, Department of Behavioral Sciences and Health Education, 1518 Clifton Road N.E., Atlanta GA 30322 (e-mail: [email protected]).

73 C 2003 Plenum Publishing Corporation 1090-7165/03/0300-0073/0 °


pp737-aibe-459290

February 24, 2003

9:32

74 paraphernalia, including rinse water, cooker, and cotton (Booth et al., 1998). Interventions aimed at sexual behavior changes tend to emphasize reduction in the number of sex partners and consistent condom use. Programs aimed at reducing sex- as well as injection drug use-related HIV risks face additional challenges (Coyle, 1998). Findings from past research among both injection and noninjection drug users reveal the extent of sexual risk reduction to be more limited than the level of drug-using risk reduction (Cottler et al., 1998; Institute of Medicine, National Academy of Sciences, 1995; Sloboda, 1998; Stephens, 1998). A number of intervention projects have demonstrated positive drug-using behavioral changes among IDUs (e.g., Booth et al., 1998; Deren et al., 1995; Hoffman et al., 1999; Latkin et al., 1996; McCoy, 1998; Siegal et al., 1995). Successful sexual behavior changes among women have been reported by researchers who have included cognitive or social cognitive, educational, and/or skills-building components into interventions and address issues of gender and social context (e.g., DiClemente and Wingood, 1995; el-Bassel and Schilling, 1992; Jemmott and Jemmott, 1992; Kelly, 1994; McCoy et al., 1998; Nyamathi et al., 1993; Wechsberg et al., 1998). Several researchers have addressed the need to develop HIV prevention, intervention, and educational efforts that are gender-specific (Amaro, 1995; Carey, 1999; Clements et al., 1997; Dekin, 1996; Ehrhardt and Exner, 2000; Newman and Zimmerman, 2000; O’Leary, 1999; Stevens et al., 1998; Wechsberg et al., 1998) and/or culturally sensitive (Airhihenbuwa et al., 1992; Freeman et al., 1999; Jemmott and Jemmott, 1992; Makulowich, 1997; Mays and Cochran, 1988; Morrison-Beedy et al., 2001; Singer, 1991; Weeks et al., 1995). The importance of considering the social and economic contexts that impact risk for all women, drug-using and nonusing, must not be overlooked in interventions aimed at preventing or reducing the risk of HIV infection (Ehrhardt and Exner, 2000; Ickovics and Yoshikawa, 1998). More recently, social contexts, such as the dynamics of heterosexual relationships, have been recognized as important considerations in interventions targeting women. Teaching women negotiation and refusal skills, for example, as opposed to teaching only condom use skills has proven to be very effective at producing positive behavior change among women (Ehrhardt and Exner, 2000). Research has also revealed the effectiveness of low-intensity (one to four sessions) compared to high-intensity (five or more sessions) programs aimed at reducing risk among women (Ickovics and Yoshikawa, 1998).


Sterk, Theall, Elifson, and Kidder Programs targeting drug-using women, however, have proven less effective at reducing heterosexual risk. In a review of 51 reported intervention studies aimed at preventing heterosexual risk behaviors among women, Ickovics and Yoshikawa (1998) concluded that although they found evidence of effectiveness at reducing risk, interventions targeting women with a history of injection drug use or among sex partners of IDUs were less likely to be effective. The authors cited reasons for such lack of positive results, such as a belief that sexual behavior is less risky than drug-using behavior or the difficulty in changing or altering intimate sexual behaviors. Relative to men who use drugs, women may be at increased risk of coming into contact with infectious individuals. Reasons for this include their greater likelihood of being initiated into injecting drug use by their male partners (Anglin et al., 1987; Rosenbaum, 1981; Sterk, 1999) and the increased probability that that their sex or drug-using partners are HIV-infected (Des Jarlais et al., 1999). The women’s position in their intimate relationships makes it difficult to initiate conversations about or propose safer needle use and sex (Deren et al., 1995; Kane, 1991; Rosenbaum, 1981). For example, a female partner who proposes each partner use a new syringe may risk verbal and physical abuse by her partner (Boyd, 1993; Weissman and National AIDS Research Consortium, 1991). It is also common for female injection drug users to support their drug habit through prostitution. Frequently, the prostitution-related sex involves unprotected highrisk HIV behaviors with multiple partners whose HIV risk status often is unknown and may be high (Sterk, 2000). As the HIV epidemic continues to affect an increasing number of women and children, particularly those who use illegal drugs, there is a continued need to motivate women at risk to reduce or eliminate their HIV risk-taking behaviors and to teach them skills that will facilitate risk reduction. The present analysis focuses on behavioral changes among female African American injection drug users following a gender- and culturally-specific HIV intervention trial conducted in Atlanta, Georgia. The purpose of this paper is to evaluate the efficacy of these interventions to help female African American IDUs make behavior changes that may reduce their risk for infection with HIV and to compare two enhanced interventions to the National Institute on Drug Abuse (NIDA) standard (NIDA, 1992). We hypothesized that women in the enhanced


pp737-aibe-459290

February 24, 2003

9:32

HIV Risk Reduction Among IDU Women intervention conditions would fare better than those in the standard conditions at 6-month follow-up.

METHODS Procedures As part of a larger HIV risk reduction trial among HIV-negative, heterosexually active, AfricanAmerican female drug injectors and crack cocaine smokers, women were recruited using street outreach techniques—including ethnographic mapping and targeted sampling (Sterk-Elifson, 1993)— in inner-city neighborhoods in the Atlanta, Georgia, metropolitan area. A total of 71 IDUs were enrolled between June 1998 and January 2001. Recruitment communities were areas within neighborhoods known for high rates of drug use, as demonstrated by epidemiologic indicators and previous ethnographic studies (Sterk, 1999; Tashima et al., 1996; Watters and Biernacki, 1989). These communities were identified using the community identification (CID) process, a mapping method for recording epidemiologic indicators of the prevalence and incidence of HIV/AIDS and substance abuse (e.g., from emergency rooms, law enforcement, and drug treatment), expert opinions (e.g., local political leaders and public health officials), and ethnographic information from local researchers (Tashima et al., 1996). The CID process also allowed us to become familiar with the local drug scene, including the different types of users, the various social contexts of use, and the associated behaviors and interaction patterns. The CID is especially effective when studying “hidden” populations as well as populations of which the parameters are unknown. Four trained African-American outreach workers, two men and two women, assisted with recruitment and mapping. To be eligible, women had to be 18 years of age or older, reside in the one of the study communities, be out of drug treatment or any other institutional setting, be proficient in English, be HIV-negative, be heterosexually active (measured as having had vaginal sex with a man at least once during the month prior to the interview), and be an active IDU (measured as having injected drugs at least three times 30 days prior to the interview). Exclusion criteria were being intoxicated or high at the time of the interview. The outreach workers used a screening form on the street to identify potential participants for participation in the intervention. An appointment was


75 scheduled for those women who met the eligibility criteria and who expressed an interest in the study. Appointments were made at the intervention site, locally known as the HIP house, with HIP standing for the Health Intervention Project. Outreach logs indicate that approximately three women needed to be approached in order to enroll a woman in the study. The main reasons for nonparticipation were a “craving,” which was defined by the women as being unable to do an interview because they were obsessed with, hustling for, or on their way to their next high, and having other obligations, most commonly child care. However, such women may have been recruited at a later date, when they were less distracted and able to better complete the baseline interview. Prior to the baseline interview, each participant was informed in detail about the purpose of the study, the procedures to ensure confidentiality, and the various steps involved with participation. The Emory University Human Investigations Committee and the Georgia State University Internal Review Board reviewed the consent procedures. After written consent was provided, a trained female interviewer administered a face-to-face, 45- to 60-min private structured interview. With the exception of one White and one black Hispanic interviewer, all other interviewers were African American. No differences were identified based on the interviewer’s racial or ethnic background. After completion of the baseline interview, participants completed a tracking form with name, address, phone numbers, address of nearest relative, nicknames, work sites, etc. The tracking information was entered in a unique database, including relevant information provided by the outreach workers, that is, information on social network connections or favorite hangouts. Women were reimbursed $15 for their participation in the baseline interview. After completion of the interview and the tracking form, participants received pretest counseling and an HIV test using Orasure (Epitope Inc., Beaverton, OR). All but 3 women returned for their HIV test results. This high return rate was largely due to the intensive community outreach that was part of the project. Posttest counseling was provided, and those who tested positive were referred to local health and social services. Women who tested negative were eligible for the intervention. Hence, all women were aware of their negative HIV serostatus. Women who tested negative for HIV antibodies were then assigned to one of the three intervention conditions. A female health interventionist, typically the same person who also conducted the pretest


pp737-aibe-459290

February 24, 2003

9:32

76 counseling and the HIV test, would again explain the study design to the participant and inform her of her intervention condition. At any given time, the project employed five interventionists and the team always included African-American women and one White woman. This was merely coincidental. However, our formative research had indicated that the racial and ethnic background of the interventionist was less salient to the women than the interventionist’s gender. Hence, all were women. Each interventionist received an intense initial 1-week training, followed by quarterly booster sessions. The training was provided by the principal investigators, local health care providers, and other experts in the field. The process evaluation, which was conducted throughout the intervention phase, facilitated the consistent implementation across subjects and within conditions. Intervention sessions were randomly audiotaped and reviewed by the project director and the principal investigators. In addition, senior project staff randomly monitored sessions. Immediate feedback was provided to the individual interventionists and comments also were included in the booster training sessions. Two interventionists, both of whom were employed part-time, were trained only in the standard intervention. This prevented any temptation to incorporate aspects of the enhanced conditions in the standard condition. Those providing enhanced interventions were trained in the negotiation as well as the motivation condition. The study’s block design allowed for a “break” between those two conditions, during which time additional training was conducted for the upcoming condition. Immediately upon completion of the intervention (2–4 weeks depending on intervention condition), the participant was invited to complete a postintervention interview, using a modified version of the baseline interview. The postintervention interview took 40–45 min and women were reimbursed $20 for their participation. In order to assess long-term (6 months) behavioral change, 6-month follow-up interviews were conducted. The average length of these interviews was 30 min and participants were reimbursed $20 for their participation.

Intervention Design The study was a randomized controlled trial using a block design. That is, only one intervention condition was conducted at a given time (typically, 1-month


Sterk, Theall, Elifson, and Kidder blocks) and all eligible women recruited during that time were assigned to the current intervention condition, regardless of their level/intensity of drug use or sexual behavior. The cycles of intervention conditions continued until the proposed research sample was complete. Upon completion of the baseline interview, collection of tracking information, and HIV counseling and testing, women were assigned to one of the three intervention conditions: (1) a four-session enhanced motivation intervention (n = 21); (2) a four-session enhanced negotiation intervention (n = 21), and (3) a NIDA standard intervention (NIDA, 1992) for drug users (n = 29). The enhanced intervention conditions were derived from a 1-year formative research phase, which showed the importance of addressing sociocultural issues in HIV prevention (Elifson and Sterk, 2003). The intervention content was empirically as well as theoretically based, using theories such as social–cognitive theory (Bandura, 1977), the theory of reasoned action (Fishbein and Middlestadt, 1989), the theory of planned behavior (Ajzen and Madden, 1986), the transtheoretical model of change (Prochaska and DiClemente, 1983), and the theory of gender and power (Connell, 1985). Central to the enhanced intervention conditions were the social context of the women’s daily lives, including the meaning of behaviors and social interactions, gender dynamics, economic stressors, gender-specific norms and values, and power and control. Incorporating this daily life context allows for prevention interventions that are sensitive to the women’s needs. The four-session enhanced intervention conditions involved individual sessions. The first session in both enhanced intervention conditions emphasized the local HIV epidemic, sex- and drug-related risk behaviors, safer sex, including the use of male and female condoms, and safer injection drug use, HIV risk reduction strategies, and the impact of race and gender on HIV risk and protective behaviors. The first session in the NIDA standard was similar to that of the enhanced conditions, excluding the impact of race and gender on HIV risk and behaviors. During the second session of the NIDA standard, participants focused on further development of HIV knowledge, and HIV risk and protective behaviors were emphasized. The enhanced conditions differed from the standard conditions. The first session of the motivation condition ended with the request to the participant to consider what things she would be motivated to change


pp737-aibe-459290

February 24, 2003

9:32


HIV Risk Reduction Among IDU Women in her life. During the second session, the participant’s change list was reviewed and short- as well as long-term goals were discussed. In addition to the participant’s past positive and negative experiences with behavioral change, her ambivalence regarding change was addressed. Based upon this discussion, short-term goals for behavioral change were set. During the third session, the participant’s experiences with the intended short-term behavioral change were reviewed, including her sense of control and feelings of ambivalence. This discussion was continued during the fourth session, which also included the delivery of risk reduction messages tailored to the participant’s level of readiness for change. The first session of the negotiation condition ended with a specific skills-training component of condom use and safe injection. In addition, participants were asked to consider which intended behavioral changes would be easy to control and which would be more complicated, for example, involve behavioral change among others, such as sex partners, as well. During the second session the list of possible behavioral changes and the level of control were reviewed. In addition, general communication skills and strategies for developing assertiveness were discussed. Based upon this, short-term goals for communication, gaining control, and developing assertiveness were set. During the third session, the participant’s experiences with the short-term goals were reviewed, as were triggers for deviating from intended goals. At this time, negotiation and conflict resolution strategies were introduced. The fourth session built on the previous sessions, including the development of tailored negotiation and conflict resolution styles. Only participants who completed all sessions were eligible for further data collection. Study Sample Sixty-eight of the 71 IDUs interviewed at baseline were reinterviewed at postintervention and 6 months after completing their assigned intervention. Overall, 96% of the women who were enrolled in the study completed the 6-month follow-up interview— 93% of women in the standard condition, 95% of women in the motivation condition, and 100% of women in the negotiation condition. Only data on participants interviewed at baseline, postintervention, and 6-month follow-up were used in this analysis. Preliminary analyses identified no differences on demographic characteristics between participants in the enhanced conditions compared to those in the stan-

77 dard condition, and there were no differences among intervention conditions between the women lost to follow-up and those followed up to 6 months. Descriptive analyses indicate that those lost to follow-up were similar to the rest of the sample demographically and with respect to sexual and drug-using behaviors. Additionally, the condition assignment procedure was successful at producing subgroups that were comparable throughout the study. We identified no significant differences in demographic characteristics at baseline, and only differences in the following sex- and drugrelated characteristics: the number of casual and paying partners, sex for drugs, and injection in a shooting gallery. These baseline differences were taken into account in analysis. The sample in the present analysis consists of 68 HIV-seronegative African-American female injection drug users. Ages ranged from 20 to 54 years, and the majority reported a very low annual income from both legal and illegal means. The most common source of income was hustling, dealing, or other activities (38%), followed by income from spouse, family, or friends (24%), wages or salary (15%), Supplemental Security Income (9%), Social Security (6%), and other public assistance, Temporary Assistance to Needy Families (TANF), or some other source (3% each). Measures In this analysis, we examine the change from baseline to postintervention to 6-month follow-up in injection drug and sexual behaviors and compare the rate of change according to intervention assignment. Key drug-using behaviors include: the number of days using powder cocaine, heroin, and a speedball (i.e., heroin/cocaine combination) in the past 30 days; the number of days that powder cocaine, heroin, and/or a speedball was injected in the past 30 days; the number of injections with used needles/syringes in the past 30 days; the number of times works or water was shared in the past 30 days; the number of injections in the past 30 days; injection setting 30 days prior to interview, including use in own home or apartment, someone else’s home, shooting gallery, outside, car, hotel room, and public restroom (yes/no for each); drug-treatment-seeking behavior, measured as recent self-initiated drug treatment attendance (0 = never to 6 = within past 2 days) and attending a self-help group (yes/no) in the past 30 days; and the number of people (e.g., partner, dealer, friends) with whom drugs were used in the past 30 days.


pp737-aibe-459290

February 24, 2003

9:32

78 Sexual behaviors, limited to heterosexual encounters, included: the number of vaginal sex partners by partner type (main, casual, or paying) in the last 30 days; the number of times vaginal, oral, or anal sex was had with each type of partner 30 days prior to interview; the frequency (0 = never to 4 = always) and consistency (i.e., always) of male condom use by partner type in the last 30 days; trading sex for drugs or trading sex for money (yes/no for both) 30 days prior to interview; use of alcohol before or during sex (both ranging from never = 0 to always = 4) in the last 30 days; having any type of sex in the last 30 days while high or with a high partner (both ranging from never = 1 to always = 5); and sex with an injection drug user (yes/no) 30 days prior to interview. Communication with most recent steady and casual partner about drug use, sexually transmitted disease (STD) history, HIV status, and past sex partners (yes/no for each) were also examined, as was the frequency of using sex to deal with worries or problems (ranging from never = 0 to always = 4). For the frequency of drug use and injection, frequency of syringe and works sharing, and the number of vaginal sex partners, we examined both the frequency of participation in behavior as well as the cessation of such behavior at follow-up (percentage participating in the behavioral practices). Very few women provided information on female condom use, the use of dental dams, or anal sex practices, and therefore such behaviors were not considered for the present analysis.

Statistical Analyses Initially we evaluated drug-using and sexual behavior change from baseline to postintervention to 6-month follow-up interviews for the entire subset of IDUs and differences in change according to intervention condition with a series of multivariate repeatedmeasures analysis of variance and logistic regression models. For all discrete outcomes Poisson regression techniques were also employed, although the outcomes were not necessarily rare events. In each case, results mirrored linear regression results, which we chose to present here. Regression was performed with the SAS procedure PROC MIXED and the SAS macro GLIMMIX (Wolfinger and O’Connell, 1993) applications, both general regression methods for fitting mathematical models to data involving repeated response measurements on the same person. These methods allow for intrasubject correlation, of-


Sterk, Theall, Elifson, and Kidder ten treated as nuisance parameters, among repeated measurements on the same subject, accounting for correlation due to repeated observations (Zeiger and Liang, 1986). The procedures employ a generalized linear mixed model (GLMM) that differs from the classic general linear model by the following: (1) In a repeated-measures analysis, it allows cases with missing data points to be retained without replacement through interpolation, means substitution, or other techniques. (2) It allows between-subject variation to be treated as a random effect (i.e., as a random source of error), removing this variation from the error term and potentially narrowing confidence intervals. (3) The estimates produced are based on maximum likelihood functions, rather than on the method of least squares. The SAS macro GLIMMIX also enables the use of non-Gaussian residual-error distributions in model specification. In examining significant overall outcomes, the main effect of time was used as the within-subject factor. To compare differences in means or proportionality between enhanced and standard conditions over time, the multiplicative interaction between intervention condition (categorical, 1–3) and time was evaluated. Due to the small sample size within conditions, overall change within each condition was not assessed at this time. Although the rate of individual change was examined, the interaction between time and intervention was of primary interest. If the interaction term is significant, there are significant intervention differences in the rate of change (i.e., regression slopes) in behavior from baseline to postintervention to 6-month follow-up, suggesting that one or more intervention groups has changed their HIVrisk practices more than another intervention group during the same time period. To identify and quantify differences among conditions on outcomes where variations in slope were observed (interaction term, p < .05), we then ran analysis of covariance (ANCOVA) or logistic regression models controlling for baseline status. Piecewise linear trends in outcomes were examined, using the reported behavior at postintervention and 6-month follow-up as the dependent variables. Independent variables included the categorical variable for intervention and the covariate, which is the reported behavior at baseline. This procedure also adjusts for any group differences in reported behavior at baseline. Age, relationship status, and sexual preference were also included as covariates in all models with sex-related behavioral outcomes, due to their association with sexual behaviors. Using the actual value of


pp737-aibe-459290

February 24, 2003

9:32


HIV Risk Reduction Among IDU Women

79

the outcome variable, rather than change in behavior, is preferable in analyses of covariance (Werts and Linn, 1970). Furthermore, the use of ANCOVA when there is random assignment to treatment or intervention groups provides a more powerful analysis of the group effect (Weinfurt, 2000). Because we were primarily interested in change at 6-month follow-up, and because ANCOVA and logistic regression results were similar for postintervention and follow-up results, we present only the results with the reported behavior at 6-month follow-up used as the dependent variable. We interpreted the intervention effect by using the relative effect size, calculated with Cohen’s formula (Cohen, 1988). This was defined as the intervention effect (difference between the score of respondents in a particular intervention condition and of those in a referent intervention condition) divided by the score of respondents in the referent condition, converted into a percentage. For the majority of behaviors evaluated, 6-month follow-up data referred to behavioral practices 30 days prior to follow-up assessment.

RESULTS Baseline characteristics of the women are provided in Table I. The majorities of women in each condition were age 41 years or older and were unemployed in the past year. A substantial proportion of participants in each condition reported having a high school diploma or GED, or beyond. Approximately 30% were married or living as married, and only 6% were homeless at baseline.

Changes for the Entire Sample of IDUs Table II presents data on participants’ drug-using behavior during the 30 days before baseline and 6-month follow-up assessment. Reported behavior at postintervention was similar enough to behavior at follow-up that only baseline and 6-month follow-up scores are presented in the table. Regardless of the intervention condition, all women reported lower levels of drug-using behaviors at follow-up. Substantial decreases ( p < .001) were found in the frequency of use and the frequency of injection of powder cocaine, heroin, and speedball, as well as in the frequency of sharing injection works or water and the number of injections. Decreases in the use ( p < .10) and injection ( p < .05) of crack cocaine were also observed. Only 7% of women reported sharing works or water at follow-up compared to 30% at baseline ( p < .01). Similarly, at follow-up only 4% reported the use of a needle used by someone else compared to 20% at baseline ( p < .05). Among those still injecting at follow-up, participants were less likely ( p < .05) to have injected with a used needle, and to inject in a shooting gallery, hotel room, public restroom, car, or outside, 30 days prior to follow-up interview. Participants also reported an increase ( p < .05) in drugtreatment-seeking behavior over time and a decline ( p < .05) in the number of people with whom drugs were used 30 days prior to interview. As was the case with drug-using behaviors, women generally reported lower levels of potentially risky sexual behaviors at 6-month follow-up, as shown in Table III. Significant decreases ( p < .05) in the number of casual and paying vaginal male sex partners

Table I. Baseline Characteristics of IDU Participants According to Intervention (N = 68)

Age (years) 18–30 31–40 41+ Mean age (µ ± SD) Education −75% for days of use and injection, p < .05). Compared to participants in the standard, those in the motivation group also reported significantly fewer days of injection (RES = −95%, p < .05), and a trend was detected ( p < .10) indicating fewer days of speedball injection (RES = −85%) and sex for drugs in the last 30 days (RES = −50%) among those in the motivation versus standard conditions. Women in the motivation group were also less likely (RES = −75%, p < .05) to have had sex for money 30 days prior to followup assessment than those in the standard condition (see Table IV). Women in the negotiation condition differed significantly ( p < .05) from women in the standard condition in the number of injections (RES = −84%), having a paying male vaginal sex partner (−68%), having sex for drugs (−78%), and having sex for money (−78%) 30 days prior to 6-month follow-up. Although only marginally significant ( p < .10), decreases in the frequency of heroin and speedball use and of speedball injection (RES > −45% for each), the number of paying partners (−67%), and use of alcohol before (−44%) or during sex (−75%) were greater among women in the negotiation condition than among those in the standard condition. Compared to women in the motivation condition, a greater proportion of those in the negotiation condition reported a significant ( p < .001) decrease in the use of alcohol during sex (RES = −83%). Women in the negotiation condition also reported fewer paying partners from baseline to follow-up assessment than women in the motivation condition (RES = −75%), though this difference was only marginally significant ( p < .10). Women in the motivation condition, however, were more likely to increase the frequency of drug treatment attendance (−40%, p < .05). There were no significant differences in the likelihood of having sex for drugs or money between the two groups, but the women in the negotiation condition were less likely (RES = −56% and −11%, respectively) at 6-month follow-up to report such behaviors (see Table IV).

83 DISCUSSION Continued risk for HIV infection among female IDUs has been well documented (Des Jarlais et al., 1999; Garfein et al., 1996; Strathdee et al., 2001). Results of our intervention trial suggest that AfricanAmerican female IDUs can make behavior changes that may reduce their risk for infection with HIV as well as other bloodborne and sexually transmitted diseases. Out-of-treatment female IDUs reduced both drug-using and sexual risk behaviors. With respect to drug use, the most pronounced changes were a reduction in the frequency of drug use and injection and in the frequency of sharing injection works and water. Women who continued to inject 30 days prior to follow-up assessment were also less likely to inject in more “risky” settings such as in a shooting gallery, outside, or in a public restroom. The most noticeable changes in sexual behavior included declines in the number of paying partners, trading sex for drugs or money, having sex while high or with a high partner, and using sex to deal with problems. Increases in communication with most recent casual partners about sensitive issues were also observed. Results also suggest that enhanced, theoretically based interventions or components of such interventions may be more effective than the NIDA standard intervention in reducing drug-using and sexual risks among similar populations of female IDUs. Our enhanced intervention conditions were more successful at reducing the frequency of drug use and risky behaviors associated with use than the NIDA standard intervention. Compared to women in the standard condition, women in both the motivation and the negotiation conditions reported significant decreases over time in the number of injections, with the magnitude of decline greatest among those in the motivation condition. Participants in the motivation condition were also more likely to increase self-initiated drug treatment attendance than those in the negotiation condition. Women in the negotiation condition, on the other hand, appear to have changed their sexual behavior more than women in other intervention conditions. Compared to women in the motivation or standard conditions, women in the negotiation condition were less likely to have a paying vaginal sex partner and to have sex for drugs. They also reported less frequent use of alcohol before or during sex. Compared to women in the standard intervention, women in the motivation condition were also more likely to have decreased the frequency of potential risky sexual


pp737-aibe-459290

February 24, 2003

9:32


84 behaviors, though not to the extent of the women in the negotiation condition. Results are consistent with the proposed hypotheses of the intervention trial. Women in the enhanced intervention conditions were expected to change drug-using and risky sexual behaviors more than women in the standard condition, and these differences were apparent. The women in the motivation condition were expected to change the circumstances under which they used drugs, and this difference was suggested. All of the women who continued to inject 30 days prior to follow-up assessment reported no use in “risky” injection settings. Similarly, women in the negotiation condition were expected to improve their negotiation skills. Such skills may come into play for behaviors such as trading sex, and women in the negotiation were more likely to report decreases in trading sex and in the number of paying partners. Traditionally negotiation skills have focused on communication in general and have stressed issues such as learning to talk about sex, introducing condom use, and other related topics. However, the negotiation condition also focused on different communication styles, for example, using assertive versus aggressive negotiation. In addition, the negotiation condition introduced the women to the principles of conflict resolution. Our process data show that these more comprehensive negotiation skills assist the women in effectively interacting with partners who want to pay them for sex when they themselves are not interested. Similar findings were reported for trading sex for drugs. The findings suggest that culturally appropriate, gender-tailored, and theoretically based interventions may be effective at enhancing HIV preventive behavior among African-American women who inject drugs. Components of both interventions used in this study may prove most useful for reducing the risk of HIV infection among similar populations of African-American women. Our findings corroborate those of others who have incorporated additional cognitive and/or attitude components in interventions among drug-using women (e.g., DiClemente and Wingood, 1995; el-Bassel and Schilling, 1992; Jemmott and Jemmott, 1992; Kelly, 1994; McCoy et al., 1998; Nyamathi et al., 1993; Wechsberg et al., 1998). Although the frequency of male condom use did increase overall among the IDUs in this study, the difference was not significant and results suggest that protected sex must continue to be stressed in prevention efforts for HIV as well as other sexually transmitted diseases.

Sterk, Theall, Elifson, and Kidder Although behavior change among the women in this study was assessed by self-report, the types of measures utilized here have been reported as adequate research tools for drug-using populations (Dowling-Guyer et al., 1994; Needle et al., 1995). Researchers have also demonstrated that there is both validity and consistency in measures of self-reported drug use and sexual behavior over time among individuals who use drugs (Adair et al., 1996). The generalizability of the findings may be limited by the unavailability of some participants for follow-up as well as the small sample size. Furthermore, long-term effects were only evaluated up to a 6-month period (Ehrhardt and Exner, 2000; Ickovics and Yoshikawa, 1998); therefore results may not reflect sustained behavior change over time. Results, however, have important implications for prevention and risk reduction among female injection drug users. As we enter yet another decade of the AIDS epidemic, HIV risk reduction prevention and intervention programs remain important. Even though women in all intervention conditions made changes in their behavior and possible risks associated with behavior (e.g., injection in a shooting gallery), additional research is needed to increase the breadth of risk reduction behavior change among women who inject drugs. Results indicate the value of including additional components in interventions designed to reduce the risk of infection with HIV among women. Researchers continue to stress the need for interventions that take the meaning and context of HIV risk into consideration. The latter includes the impact of relatives, peers, and partners as well as the community at large, including economic and legal factors (Battjes et al. 1994; Ickovics and Yoshikawa, 1998; Miller and Neaigus, 2001). ACKNOWLEDGMENTS This research was supported by NIDA grant R01 DA-10642 and the Emory Center for AIDS Research. The views presented in this paper are those of the authors and do not represent those of the funding agencies. We thank Hugh Klein and Laura Lloyd for their assistance on earlier drafts of this paper. We also wish to thank all the field staff and the participants who made this study possible. REFERENCES Adair, E. B., Craddock, S. G., Miller, H. G., and Turner, C. F. (1996). Quality of treatment data. Reliability over time of self-reports


pp737-aibe-459290

February 24, 2003

HIV Risk Reduction Among IDU Women given by clients in treatment for substance abuse. Journal of Substance Abuse Treatment, 13, 145–149. Airhihenbuwa, C. O., DiClemente, R. J., Wingood, G. M., and Lowe, A. (1992). HIV/AIDS education and prevention among African-Americans: A focus on culture. AIDS Education and Prevention, 4, 267–276. Ajzen, I., and Madden, T. J. (1986). Prediction of goal-directed behavior: Attitudes, intentions, and perceived behavioral control. Journal of Experimental Social Psychology, 22, 453–474. Amaro, H. (1995). Love, sex, and power: Considering women’s realities in HIV prevention. American Psychologist, 50, 437– 447. Anglin, M. D., Hser, Y. I., and McGlothlin, W. H. (1987). Sex differences in addict careers. 2. Becoming addicted. American Journal of Drug and Alcohol Abuse, 13, 59–71. Bandura, A. (1977). Self-efficacy. Psychological Review, 84, 191– 215. Battjes, R. J., Pickens, R. W., Haverkos, H. W., and Sloboda, Z. (1994). HIV risk factors among injecting drug users in five U.S. cities. AIDS, 8, 681–687. Booth, R. E., Kwiatkowski, C. F., and Stephens, R. C. (1998). Effectiveness of HIV/AIDS interventions on drug use and needle risk behaviors for out-of-treatment injection drug users. Journal of Psychoactive Drugs, 30, 269–278. Booth, R. E., Kwiatkowski, C. F., and Chitwood, D. D. (2000). Sex related HIV risk behaviors: Differential risks among injection drug users, crack smokers, and injection drug users who smoke crack. Drug and Alcohol Dependence, 58, 219–226. Boyd, C. J. (1993). The antecedents of women’s crack cocaine abuse: Family substance abuse, sexual abuse, depression and illicit drug use. Journal of Substance Abuse Treatment, 10, 433– 438. Carey, M. P. (1999). Motivational strategies can enhance HIV risk reduction programs. AIDS and Behavior, 3, 269–276. Centers for Disease Control and Prevention. (2001). HIV/AIDS surveillance in women. Available at http://www.cdc.gov/hiv/ graphics/women.htm; accessed September 27, 2001. Clements, K., Gleghorn, A., Garcia, D., Katz, M., and Marx, R. (1997). A risk profile of street youth in northern California: Implications for gender-specific human immunodeficiency virus prevention. Journal of Adolescent Health, 20, 343–353. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Erlbaum. Connell, R. W. (1985). Theorising gender. Sociology, 19, 260–272. Cottler, L. B., Leukefeld, C., Hoffman, J., Desmond, D., Wechsberg, W., Inciardi, J. A., Compton, W. M., Ben Abdallah, A., Cunningham-Williams, R., and Woodson, S. (1998). Effectiveness of HIV risk reduction initiatives among out-of-treatment non-injection drug users. Journal of Psychoactive Drugs, 30, 279–290. Coyle, S. L. (1998). Women’s drug use and HIV risk: Findings from NIDA’s cooperative agreement for community-based outreach/intervention research program. Women and Health, 27, 1–18. Dekin, B. (1996). Gender differences in HIV-related self-reported knowledge, attitudes, and behaviors among college students. American Journal of Preventive Medicine, 12, 61–66. Deren, S., Davis, R., Tortu, S., Beardsley, M., I. Ahluwalia, and National AIDS Research Consortium. (1995). Women at highrisk for HIV: Pregnancy and risk behaviors. Journal of Drug Issues, 25, 57–71. Des Jarlais, D. C., Friedman, S. R., Perlis, T., Chapman, T. F., Sotheran, J. L., Paone, D., Monterroso, E., and Neaigus, A. (1999). Risk behavior and HIV infection among new drug injectors in the era of AIDS in New York City. Journal of Acquired Immune Deficiency Syndromes, 20, 67–72. DiClemente, R. J., and Wingood, G. M. (1995). A randomized controlled trial of an HIV sexual risk-reduction intervention

9:32


85 for young African-American women. Journal of the American Medical Association, 274, 1271–1276. Dowling-Guyer, S., Johnson, M. E., Fisher, D. G., and Needle, R. (1994). Reliability of drug users’ self-reported HIV risk behaviors and validity of self-reported recent drug use. Assessment, 1, 383–392. Ehrhardt, A. A., and Exner, T. M. (2000). Prevention of sexual risk behavior for HIV infection with women. AIDS, 14, S53–S58. el-Bassel, N., and Schilling, R. F. (1992). 15-month follow-up of women methadone patients taught skills to reduce heterosexual HIV transmission. Public Health Reports, 107, 500–504. Elifson, K. W., and Sterk, C. E. (2003). Case study: The health intervention project. In D. Blumenthal and R. DiClemente (Eds.), Community-based research: Issues and methods. New York, Springer. Fishbein, M., and Middlestadt, S. E. (1989). Using the theory of reasoned action as a framework for understanding and changing AIDS-related behaviors. In J. N. Wasserheit (Ed.), Primary prevention of AIDS: Psychological approaches (pp. 93–110). Thousand Oaks, CA: Sage. Freeman, R. C., Williams, M. L., and Saunders, L. A. (1999). Drug use, AIDS knowledge, and HIV risk behaviors of Cuban-, Mexican-, and Puerto-Rican-born drug injectors who are recent entrants into the United States. Substance Use and Misuse, 34, 1765–1793. Garfein, R. S., Vlahov, D., Galai, N., Doherty, M. C., and Nelson, K. E. (1996). Viral infections in short-term injection drug users: The prevalence of the hepatitis C, hepatitis B, human immunodeficiency, and human T-lymphotropic viruses. American Journal of Public Health, 86, 655–661. Ickovics, J. R., and Yoshikawa, H. (1998). Preventive interventions to reduce heterosexual HIV risk for women: Current perspectives, future directions. AIDS, 12, S197–S208. Institute of Medicine, National Academy of Sciences. (1995). Assessing the social and behavioral science base for HIV/AIDS prevention and intervention: Workshop summary. Washington, DC: National Academy Press. Jemmott, L. S., and Jemmott, J. B. (1992). Increasing condom-use intentions among sexually active Black adolescent women. Nursing Research, 41, 273–279. Kane, S. (1991). HIV, heroin and heterosexual relations. Social Science and Medicine, 32, 1037–1050. Kelly, J. A. (1994). Sexually transmitted disease prevention approaches that work. Interventions to reduce risk behavior among individuals, groups, and communities. Sexually Transmitted Diseases, 21, S73–S75. Makulowich, G. S. (1997). Certain social and cultural factors put women at risk of HIV infection. AIDS Patient Care and STDs, 11, 201. Mays, V., and Cochran, S. (1988). Interpretation of AIDS risk and risk reduction activities by Black and Hispanic women. American Pyschologist, 43, 949–957. Miller, M., and Neaigus, A. (2001). Networks, resources and risk among women who use drugs. Social Science and Medicine, 52, 967–978. Morrison-Beedy, D., Carey, M. P., Lewis, B. P., and Aronowitz, T. (2001). HIV risk behavior and psychological correlates among Native American women: An exploratory investigation. Journal of Women’s Health and Gender-Based Medicine, 10, 487– 494. National Institute on Drug Abuse. (1992). The standard intervention of the cooperative agreement program for AIDS community-based outreach/intervention research. Cooperative Agreement Steering Committee, January 9–10, 1992. Needle, R., Fisher, D. G.,Weatherby, N., Chitwood, D., Brown, B., Cesari, H., Booth, R., Williams, M. L., Watters, J., Andersen, M., and Braunstein, M. (1995). Reliability of self-reported HIV risk behaviors of drug users. Psychology of Addictive Behaviors, 9, 242–250.


pp737-aibe-459290

February 24, 2003

9:32

86 Needle, R., Coyle, S. L., Normand, J., Lambert, E., and Cesari, H. (1998). HIV prevention with drug-using populations— Current status and future prospects: Introduction and overview. Public Health Reports, 113, 4–18. Newman, P. A., and Zimmerman, M. A. (2000). Gender differences in HIV-related sexual risk behavior among urban African American youth: A multivariate approach. AIDS Education and Prevention, 12, 308–325. Nyamathi, A. M., Leake, B., Flaskerud, J. H., Lewis, C., and Bennett, C. (1993). Outcomes of specialized and traditional AIDS counseling programs for impoverished women of color. Research in Nursing and Health, 16, 11–21. O’Leary, A. (1999). Preventing HIV infection in heterosexual women: What do we know? What must we learn? Applied and Preventive Psychology, 8, 257–263. Prochaska, J., and DiClemente, C. (1983). Stages and processes of self-change of smoking. Journal of Consulting and Clinical Psychology, 51, 390–395. Rosenbaum, M. (1981). Women on heroin. New Brunswick, NJ: Rutgers University Press. Singer, M. (1991). Confronting the AIDS epidemic among IV drug users: Does ethnic culture matter? AIDS Education and Prevention, 3, 258–283. Sloboda, Z. (1998). What we have learned from research about the prevention of HIV transmission among drug abusers? Public Health Reports, 113, 194–204. Stephens, R., Simpson, S., Coyle, S., et al. (1993). Comparative effectiveness of NADR interventions. In B. Brown and G. Beschner (Eds.), Handbook on risk of AIDS (pp. 519–556). Westport, CT: Greenwood. Sterk, C. E. (1999). Fast lives: Women who use crack cocaine. Philadelphia: Temple University Press. Sterk, C. E. (2000). Tricking and tripping: Prostitution in the era of AIDS. Putnam Valley, NY: Social Change Press. Sterk-Elifson, C. (1993). Outreach among drug users: Combining the role of ethnographic field assistant and health educator. Human Organization, 52, 162–168.


Sterk, Theall, Elifson, and Kidder Stevens, S., Tortu, S., and Coyle, S. L. (1998). Women drug users and HIV prevention: Overview of findings and research needs. Women and Health, 27, 19–23. Strathdee, S. A., Galai, N., Safaiean, M., Celentano, D. D., Vlahov, D., Johnson, L., and Nelson, K. E. (2001). Sex differences in risk factors for HIV seroconversion among injection drug users—A 10-year perspective. Archives of Internal Medicine, 161, 1281–1288. Tashima, N., Crain, S., O’Reilly, K., and Sterk-Elifson, C. (1996). The community identification process: A discovery model. Qualitative Health Research, 6, 23–48. Watters, J. K., and Biernacki, P. (1989). Targeted sampling: Options for the study of hidden populations. Social Problems, 36, 416– 430. Wechsberg, W. M., Dennis, M. L., and Stevens, S. J. (1998). Cluster analysis of HIV intervention outcomes among substanceabusing women. American Journal of Drug and Alcohol Abuse, 24, 239–257. Weeks, M., Schensul, J., Williams, S., Singer, M., and Grier, M. (1995). AIDS prevention for African-American and Latino women. AIDS Education and Prevention, 7, 251–263. Weinfurt, K. P. (2000). Repeated measures analyses: ANOVA, MANOVA, and HLM. In L. G. Grimm and P. R. Yarnold (Eds.), Reading and understanding more multivariate statistics (pp. 317–361). Washington, DC: American Psychological Association. Weissman, G., and National AIDS Research Consortium. (1991). AIDS Prevention for women at risk. AIDS Education and Prevention, 12, 49–63. Werts, C. E., and Linn, L. (1970). A general linear model for studying growth. Psychological Bulletin, 73, 17–22. Wolfinger, R., and O’Connell, M. (1993). Generalized linear mixed models: A pseudo-likelihood approach. Journal of Statistical Computation and Simulation, 48, 233–244. Zeiger, S. L., and Liang, K. Y. (1986). Longitudinal data analysis for discrete and continuous outcomes. Biometrics, 42, 121– 130.