World Journal of AIDS, 2012, 2, 183-193 Published Online September 2012 ( 183
Prevalence of Human Immunodeficiency Virus (HIV), Risk
Behavior, and Recent Substance Use in a Sample of Urban
Drug Users: Findings by Race and Sex
Rebecca C. Trenz1*, Lauren R. Pacek2, Michael Scherer2, Paul T. Harrell2, Julia Zur2,
William W. Latimer3
1Department of Psychology, School of Social and Behavioral Sciences, Mercy College, Dobbs Ferry, New York, USA; 2Department
of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA; 3Department of Clinical and
Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, USA.
Email: *
Received July 5th, 2012; revised August 5th, 2012; accepted August 12th, 2012
The aim of the current study was to examine the prevalence of HIV, past six-month illicit d rug use, and risk behaviors
among a population of heavy drug users living in an urban setting. Although many studies investigate substance use,
sex-risk behavior, and HIV by race and gender, no studies have examined these variables simultaneously. The current
study seeks to fill this gap in the literature by exploring HIV prevalence among a predominantly heterosexual sample of
recent substance users by injection drug use (IDU) status, race, and sex. Baseline data from the Baltimore site of the
NEURO-HIV epidemiologic study was used in this study. This study examines neuropsychological and social-behav-
ioral risk factors of HIV, hepatitis A, hepatitis B, and hepatitis C among both injection and non-injection drug users.
Descriptive statistics and chi-square statistics were used in data analyses. Blood and urine samples were obtained to test
for the presence of recent drug use, viral hepatitis, HIV, and other sexually transmitted diseases (STDs). Findings pre-
sented here have several important implications for HIV prevention and care among substance users. Intervention pro-
grams that incorporate substan ce use treatment in addition to HIV education, particularly with respect to substance use
and sex risk behavior are imperative.
Keywords: HIV Prevalence; Injection Drug Use; Non-Injection Drug Use; Sex Risk Behavior
1. Introduction
Traditionally, early HIV prevalence research in the
United States has focused on two high-risk categories:
injection drug users (IDUs) [1-7] and men who have sex
with men (MSM) [8-13]. Over one million cases of
AIDS have been documented in the United States since
the beginning of the epidemic with the majority of these
cases occurring within major metropolitan areas [14]. In
Maryland, HIV is the fourth leading cause of death
among Blacks [15] and not unlike many other cities in
the United States, Baltimore has a significant prevalence
of HIV. As of 2006 in Baltimore City, Maryland , 2454.7
individuals per 100,000 were living with HIV/AIDS with
an annual incidence of approximately 37.7 cases per
100,000, ranking the city second among metropolitan
areas in the United States. [16]
In addition to high prevalence of HIV in Baltimore,
within Maryland, an estimated 7% - 19% of residents
reported illicit drug use in the past month and past year
alcohol or illicit drug use, dependence, or abuse [17].
Moreover, substance use has a strong link to HIV/AIDS
in the United States. It is estimated that approximately
64% of individuals diagnosed with HIV/AIDS have used
a non-injection illicit drug and 17% have used an injec-
tion drug in their lifetime [14]. In fact, landmark studies
of HIV and substance use specifically examined injection
drug use (IDU) with a focus on HIV transmission via
needle sharing [2-4]. Additionally, other early studies
suggested that sexual transmission among IDUs also ex-
isted, but was overshadowed by injection risks [5-7].
Currently, the Centers for Disease Control and Prevention
(CDC) estimates that about 13% of new HIV-positive di-
agnoses are attributable to IDU [18]. Furthermore, IDUs
represent a high-risk group for HIV transmission that may
bridge the gap to lower-risk populations, such as non-injec-
tion drug users (NIDUs) [19-20], through sex-risk behaviors
[22]. As a resu lt, research has b egun to focus on the preva-
lence of HIV infection among substance users generally,
*Corresponding a uthor.
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Prevalence of Human Immunodeficiency Virus (HIV), Risk Behavior, and Recent Substance Use in a
Sample of Urban Drug Users: Findings by Race and Sex
expanding the literature to include NIDUs [21] with a
focus on sexual transmission risk [20,23-25].
Although the current literature is ex panding to include
non-injection drug use (NIDU) and risk behaviors asso-
ciated with substance use in general, few studies have
included IDU status, race, and sex along with HIV
prevalence in the same study. In addition HIV prevalence
information among NIDUs is often gathered from re-
search conducted on populations of substance abusing
HIV-positive individuals either seeking treatment or cur-
rently enrolled in treatment programs. The aim of the
current study was to examine the p r ev a len ce of H IV , p a s t
six-month illicit drug use, and risk behaviors among a
population of heavy drug users living in an urban setting.
As HIV prevalence research has focused on the afore-
mentioned categories, fewer studies have investigated the
occurrence of HIV among primarily heterosexual, sub-
stance using samples that include both Black and White
injection and non-injection drug users. The current study
seeks to fill this gap in the literature by exploring HIV
prevalence among a predominately heterosexual sample
of recent substance users by IDU status, race, and sex.
2. Method
Data for this study were obtained from the baseline as-
sessment of the NEURO-HIV Epidemiologic Study. This
study was designed to examine neuropsychological and
social-behavioral risk factors of HIV, hepatitis A, hepati-
tis B, and hepatitis C among both injection and non-in-
jection drug users in Baltimore, Maryland. This study
was approved by the Institutional Review Board at the
Johns Hopkins Bloomberg School of Public Health in
2001 and has received annual renewals. The design of
this study is cross-section al. In ord er to b e eligible fo r the
parent study, participants had to be between the ages of
15 and 50 and had to report use of non-injection and/or
injection drugs in the past 6 months. Participants who
met these criteria were selected for the current research.
Recruitment strategies for participation included adver-
tisements in local papers, street outreach, and referrals
from local service agencies. Participants were remuner-
ated $45 for the baseline assessment.
Participants provided written informed consent and
completed a face-to-face HIV-risk behavior interview. In
addition, participants completed a battery of neuropsy-
chological tests that measured executive functioning and
estimated general intelligence. Blood and urine samples
were also collected at the baseline assessment. Blood was
drawn by a phlebo tomist and tested for HIV, hepatitis A,
B, and C. Urine samples were tested for the presence of
drugs including: opiates, cocaine, cannabinoids, metham-
phetamine, methadone, PCP, barbiturates, benzodiazepi-
nes, tricyclic antidepressants, MDMA, and oxycodone.
Participants were subsequently notified of their HIV
status and were referred to drug treatment and social ser-
vices for counseling with respect to their blood and urine
analysis results.
2.1. Study Participants
Participants for the research presented here were drawn
from the metropolitan region of Baltimore, Maryland.
Residents of this region have a median age of 34.40 years
and are primarily African American (63.7%), have a high
school or greater education (76.9%), and have never been
married (males 54.5%; females 49.2%) [26]. Participants
included in the current study (N = 578) identified as
Black (48.1%) or White (57.9%) with a mean age of
31.57 (SD = 7.76). The majority of participants were
male (56.6%) and single (70.1%) with a high school
education or greater (55.0%). Approximately 19.0% re-
ported having experienced homelessness and 37.8% re-
ported receiving public assistance in the 6 months prior
to the study assessment. In addition, 75.0% of partici-
pants reported having been either in jail or a correctional
facility in their lifetime. Table 1 shows a complete sum-
mary of characteristics of the study sample.
2.2. Measures
2.2.1. HIV-Risk Behavior Interview
The HIV-risk behavior interview is a detailed behavioral
assessment of drug use and sexual practices. This as-
sessment was adapted from a similar interview used in
the REACH [19] and ALIVE [27] studies. Questions
addressed demographic, educational, medical, and neu-
rodevelopment variables along with a detailed assessment
of lifetime and recent drug use and sexual practices includ-
ing a history of sexually transmitted diseases (STDs) [28].
2.2.2. C asual Sex Be havior
Participants were asked two questions assessing casual
sex and risk: “Have you ever had a casual partner?” and
“When you had sex with a casual partner, what percent
of the time did you use a condom?” A casual partner is
defined as having sex with someone whom the partici-
pant knew for less than three months. A dichotomous
variable was created to identify participants who ever
had casual sex (coded 1) versus those who did not (coded
0). Consistent condom use with a causal partner, or using
a condom 100% of the time with a casual partner was
coded 1 and inconsistent condom use with casual partner
(0% - 99%) was coded 0. Studies investigating sex risk
behavior have utilized this type of co ding method to cate-
gorize consistent versus inconsistent condom use [28].
2.2.3. Se x Trade
Participants were asked if they had ever paid for sex with
Copyright © 2012 SciRes. WJA
Prevalence of Human Immunodeficiency Virus (HIV), Risk Behavior, and Recent Substance Use in a
Sample of Urban Drug Users: Findings by Race and Sex
Copyright © 2012 SciRes. WJA
Table 1. Characteristics of the study sample (N = 578).
Frequency or Mean % or SD
Age (range = 15 - 50 years) 31.57 7.76
Black 278 48.1
White 300 57.9
Male 327 56.6
Female 251 43.4
Less than high school graduate 260 36.5
High school graduate or equivalent 227 39.3
Some college or technical training 84 14.5
College graduate 7 1.2
Marital Status
Single 404 70.1
Separated 47 8.2
Divorced 57 9.9
Widowed 11 1.9
Married 57 9.9
Homeless past 6 months 107 18.9
Received public assistance past 6 months 218 37.8
Incarcerati on history
Never in jail 143 25.0
Jail 262 45.9
Correctional facility 166 29.1
Sexual history
Opposite sex partners only 556 97.4
Ever had casual sex 401 70.0
Ever trade sex 190 32.9
Casual partners 28.43 167.69
HIV-positive 46 8.0
Any STD 169 30.2
Lifetime i nj e ct i on drug use 370 64.0
Recent substance usea
Cigarettes 517 89.4
Alcohol 421 72.8
Inject any drug 314 54.3
Marijuana-smoking 307 53.2
Heroin-injection 291 50.3
Crack Cocaine 273 47.3
Heroin-nasal 259 44.9
Heroin and cocaine together (“Speedball”): injection 184 31.9
Cocaine-injection 182 31.5
“Downers” (barbiturates, tranquilizers, sedatives, etc.) 130 22.5
Cocaine-nasal 121 21.0
Street methadone 106 18.3
Note: Column totals do not always add up to the sample total due to missing data (<2%); aPast six months.
Prevalence of Human Immunodeficiency Virus (HIV), Risk Behavior, and Recent Substance Use in a
Sample of Urban Drug Users: Findings by Race and Sex
drugs or money or sold sex for drugs or money. These
two variables were collapsed into one sex trade variable.
Participants who resp onded “yes” to either on e or both of
these questions were coded 1, while those who responded
no to both were coded 0.
2.2.4. Se xually T r a ns mitted D iseases
Participants were asked if they had ever been told by a
health professional that they had a STD including gon-
orrhea, syphilis, chlamydia, genital herpes, gen ital warts,
or trichomoniasis. A dichotomous variable was created to
identify any participants with (coded as 1) or without
(coded as 0 ) a h istory o f o n e of these s ix STDs.
2.2.5. Recent Substance Use
Participants were asked if they had used any of the fol-
lowing substances in the six months prior to the assess-
ment: cigarettes, alcoho l, any drug inj ection , marijuan a—
smoking, heroin—injection, crack cocaine, heroin—nasal,
heroin and cocaine together (“Speedball”), cocaine—
injection, “downers” (barbiturates, tranquilizers, seda-
tives, etc.), cocaine—nasal, and street methadone. “Yes”
responses were coded 1, while “no” responses were
coded 0 f or each substance.
2.2.6. Substance Use before/during Sex
Participants were asked three questions each for lifetime
substance use before/during casual sex: “When you had
sex with a casual partner, what percent of the time did
you use alcohol before /during sex?”; “When you had sex
with a casual partner, what percent of the time did you
use non-injection drugs before/during sex?”; and “When
you had sex with a casual partner, what percent of the
time did you use injection drugs before/during sex?”
Those participants who responded 0% to any of these
items were coded as 0. Those who indicated any per-
centage greater than 0 were coded 1. This same set of
questions was asked substituting “steady partner” for
“casual partner.” A steady partner is defined as a rela-
tionship greater than 3 months. For both casual and
steady sex, the above three questions were collapsed in to
one variable, any drug use before/during sex. In both
instances, any drug use befor e/ duri n g sex w a s code d 1.
2.3. Data Analysis
Descriptive statistics were used to calculate frequencies,
means, and percentages for each variable of interest.
Race/sex groups (White male, Black male, White female,
Black female) were created to conduct ANOVAs and
chi-square statistics (χ2) for demographic, sex-risk be-
havior, recent substance use, and substance use be-
fore/during sex variables. Tukey HSD post hoc compari-
sons were used for ANOVAs. The frequency of HIV-
positive cases was calculated for the entire study sample.
HIV-positive cases were then further stratified by IDU
status, race, and sex. In the analysis of HIV-positive
cases by IDU status, race, and sex, chi-square statistics
were calculated where possible; in other words, the as-
sumptions that 80% or more of the cells have expected
frequencies of five or more and that no cells have an ex-
pected count of 0 must have been met [29]. In situations
where a 2 by 2 table was evaluated, the Yates Correction
for Continuity was used as the test for significance [29].
All data analysis was performed using PASW Statistics
18 [30].
3. Results
3.1. Participant Characteristics
Table 1 displays the prevalence of baseline characteris-
tics including sexual history, and recent substance use.
The majority of participants reported having only oppo-
site sex sexual partners (97.4%) in their lifetime. Seventy
percent of participants reported having had casual sex in
their lifetime with a mean of 28.43 (SD = 167.69) casual
partners. The prevalence of lifetime sex trade in study
participants was 32.9%. Overall, HIV seroprevalence
was 8.0% (46 HIV-positive cases) and just under one-
third (30.2%) reported having been told they had any
STD. Sixty-four percent of participants reported ever
injecting any drug in their lifetime.
Overall, there was a high prevalence of recent sub-
stance use in the study sample. Greater than half of the
sample reported using cigarettes (89.4%), alcohol (72 .8 %),
injecting any drug (54.3%), smoking marijuana (53.2%),
and injecting heroin (50.3%) in the six months prior to
the assessment. Crack cocaine (47.3%), nasal heroin
(44.9%), “Speedball” (31.9%), and injecting cocaine
(31.5%) had high recent prevalence of use. Although
less prevalent, “Downers” (22.5%), nasal cocaine (21.0%),
and street methadone (18.3%) are included as representa-
tive of recent substance use.
3.2. Associations of Participant Characteristics
by Race and Sex
Table 2 displays a full summary of associations of
demographics, sex-risk behaviors, recent substance use,
and substance use before/during casual and steady sex by
race/sex group.
3.2.1. Baseline Characteristics
One-way ANOVA r evealed significan t differences in age
by race/sex group, F(3,577) = 31.68, p < 0.001. As re-
vealed by post-hoc analysis, White males were signifi-
cantly younger (M = 28.50, = 7.42) than both Black SD
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Prevalence of Human Immunodeficiency Virus (HIV), Risk Behavior, and Recent Substance Use in a
Sample of Urban Drug Users: Findings by Race and Sex 187
Table 2. Association of baseline participant characteristics in 578 substance users
Note: aPas t s ix months; bLifetime.
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Prevalence of Human Immunodeficiency Virus (HIV), Risk Behavior, and Recent Substance Use in a
Sample of Urban Drug Users: Findings by Race and Sex
males (M = 35.06, SD = 6.72), p < 0.001, and Black fe-
males (M = 33.70, SD = 7.22), p < 0.001. Similarly
White females were significantly younger (M = 28.74,
SD = 7.43) than Black males, p < 0.001, and Black fe-
males, p < 0.001. Chi-square statistics revealed signifi-
cant differences by group on high school education/GED,
p < 0.001; single status, p = 0.002; spending time in jail,
p < 0.001; receiving public assistance, p < 0.001; home-
lessness, p < 0.001; having ever injected any drug, p <
0.001; testing pos itive for opioids, p < 0.001; being HIV-
positive, p < 0.001; and having any STD, p < 0.001.
3.2.2. Sex-Risk Beh avior
Chi-square analyses revealed significant differences by
group on ever engaging in casual sex, p < 0.001, and
having traded sex, p < 0.001. More than three-fourths of
both White (83.4%) and Black (79.7%) males reported
casual sex in their lifetime. The highest percentage of sex
trade involvement was found among Black males (43.6%)
and the lowest was among White males (21.4%). One-
way ANOVA revealed significant differences in number
of lifetime casual sex partners by group, F(3,395) = 9.40,
p < 0.001. Post ho c analysis showed that both White and
Black males had significantly more casual partners (M =
24.65, SD = 34.61; M = 28.86, SD = 47.15, respectively)
than Black females (M = 5.94, SD = 8.64), p < 0.001.
Black males also had significantly more casual partners
than White females (M = 11.56, SD = 18.88), p = 0.017.
There was no significant difference by group on consis-
tent condom use with casual partners, p = 0.187. Consis-
tent condom use across groups was low with Black fe-
males reporting the highest percentage (37.6%) of con-
sistent condom use with casual partners.
3.2.3. Recent Substance Use
Chi-square analyses revealed significant differences by
group on recent substance use, including: heroin—in-
jection, p < 0.001; heroin—nasal, p < 0.001; cocaine—
injection, p < 0.001; cocaine—nasal, p = 0.007; “speed-
ball” —injection, p < 0.001; and “down ers”, p < 0.00 1. A
large percentage of White males (75.9%) and White fe-
males (70.3%) endorsed having injected heroin in the past
six months compared to Black males (32.1%) and Black
females (25.0%). Conversely, nasal heroin use for Black
males (59.3%) and Black females (46.9%) exceeded that for
White males (33.7%) and White females (42.2%). No
significant differences were found by group on crack co-
caine, p = 0.321, or street methadone use, p = 0.085.
3.2.4. Substance Use before/during Casual Sex
Chi-square analyses revealed significant differences by
group on alcohol use, p = 0.019, non-injection drug use,
p < 0.001, injection drug use, p = 0.001, and any drug
use, p < 0.016, before/during casual sex. The highest
rates of alcohol use before/during casual sex were found
among White males (68.4%) and Black males (68.8%).
High rates of non-injection drug use before/during sex
were also found among White males (60.0%) and Black
males (74.3%). The use of any drug before/during sex
was high across groups, with the highest prevalence
among Black males (85.3%).
3.2.5. Substance Use before/during Steady Sex
Chi-square analyses revealed significant differences by
group on alcohol use, p = 0.010, non-injection drug use,
p = 0.013, and injection drug use, p < 0.001, be-
fore/during steady sex. Substance use before/during sex
was high across groups with more than half of partici-
pants in each group reporting alcohol use and non-injec-
tion drug use in these situations. Injection drug use be-
fore/during sex was highest among White females
(57.5%) and lowest among Black females (23.9%). No
significant differences were found between groups on
any drug use before/during sex, however rates of use in
this situation were high across all gro ups with prevalen ce
exceeding 75% within each group.
3.3. HIV Prevalence by IDU Status, Race, and
A summary of HIV-positive cases can be found in Fig-
ure 1. Overall, of the 578 participants screened in the
current study 7.96% were HIV-positive. There was no
significant difference in HIV-positive cases by IDU
2 = 0.00, p = 1.00. The prevalence of HIV-posi-
tive cases among injectors (7.96%) and non-injectors
(7.95%) was similar. Among injectors, Black injectors
more likely to be HIV-positive (16.83%) than White in-
jectors (3.76%),
2 = 14.25, p < 0.001. Among Black
injectors, there was no significant difference found by
sex, where prevalence of HIV-positive cases was 19 .23%
for males and 14.29% for females,
2 = 0.16, p = 0.691.
Among non-injectors, there was a significant difference
found by race, where Black non-injectors were more
likely to be HIV-positive (10.55%) than Whites (0%) in
this group,
2 = 6.08, p = 0.014. No significant difference
in sex was found among Black non-injectors,
2 = 0.01, p
= 0.921. Among Black non-injectors, the prevalence of
HIV-positive cases for males was 11.36% and 9.91% fo r
females. Chi-square analysis was not conducted among
White injectors and non-injectors due to violations of
lowest expected frequencies.
Two additional analyses were conducted across inject-
tion drug use status comparing Black male injectors to
Black male non-injectors and Black female injectors to
Black female non-injectors. First, there was no signifi-
cant difference found between Black males by IDU
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Prevalence of Human Immunodeficiency Virus (HIV), Risk Behavior, and Recent Substance Use in a
Sample of Urban Drug Users: Findings by Race and Sex 189
Figure 1. Flow chart illustrating the prevalence of HIV+ status in the study sample. Ellipses represent injection drug use status, rectangles represent race/ethnicity,
and circles represent sex. Chi-squares were conducted in cases where at least 80% of cells have expected frequencies of 5 or more.
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Prevalence of Human Immunodeficiency Virus (HIV), Risk Behavior, and Recent Substance Use in a
Sample of Urban Drug Users: Findings by Race and Sex
2 = 1.07, p = 0.300. The prevalence of HIV-
positive cases for Black male injectors was 19.23%
compared to 11.36% among Black male non-injectors.
Second, there was no significant difference found be-
tween Black females by IDU status, where 14.29% of
Black female injectors were HIV-positive compared to
9.91% of Black female non-injectors,
2 = 0.29, p =
4. Discussion
The purpose of the present study was to evaluate demo-
graphic characteristics, sex-risk behavior, substance use,
and prevalence of HIV by IDU status, race, and sex
among a population of primarily heterosexual, recent
substance users. There are several important findings that
should be discussed. First, sex-risk behavior across
race/sex groups is high with low levels of consistent
condom use with casual partners. Second, substance use
before/during both casual and steady sex is high across
groups. These findings are particularly pertinent since it
is known that alcohol and drug use impairs judgment and
decision making that could lead to sex-risk behaviors
such as inconsistent condom use, contributing to HIV
transmission and infection. This finding is acutely im-
portant for Baltimore, given that of the HIV cases re-
ported by the Maryland Department of Health and Men-
tal Hygiene in Baltimore City, the majority are hetero-
sexuals (47%) followed by injection drug users (IDUs;
32%) and men who have sex with men (MSM; 16%) [16].
In addition, this study supports recent findings that
prevalence of HIV is similar when broken down by in-
jection drug use status, yet within these two categories
HIV prevalence is greater for both Black males and fe-
males compared to White males and females [31]. More-
over, these findings are consistent with national estimates
of race disparities in HIV identifying Blacks with the
highest prevalence of new HIV/AIDS diagnoses (50.5%),
while representing only 13% of the population [32]. The
disparities in HIV infection by race are well-documented
and there are several proposed theoretical explanations
for this finding. One prominent explanation is that HIV
transmission among NIDUs likely occurs from high-risk
sexual behaviors [20,31]. The findings in the current
study provide some support for this theory in that sex
trade is more prominent among African Americans and
suggests that for Black males and females the prevalence
of HIV is similarly attributable to risky injection prac-
tices among IDUs and risky sexual behavior among
Although race itself is not a risk factor for becoming
infected with HIV, there are many factors that may con-
tribute to the disparities in HIV infection explored in the
literature. In particular, a large number of studies have
explored social network structure as a potential source of
these disparities, particularly among IDUs [23,33,34].
However, recently research has begun to focus on high-
risk sexual behaviors of heterosexual substance users.
For example, in a study of primarily African Americans
in a high HIV-risk community, drug users were more
likely than non-drug users to have multiple sex partners,
exchange sex for money or drugs, have a sexual rela-
tionship with someone they knew had other sex partners,
and use drugs or alcohol at their last sexual experience
compared to non-drug users [20]. In addition, in a sample
of African American NIDUs, having personal networks
with a high degree of substance use activities and re-
ceiving financial support in the form of housing assis-
tance was associated with high-risk sexual behaviors
including having multiple partners and having sex with-
out a condom [24].
Although no significan t differences were found by sex
with regard to HIV prevalence in the current study, fe-
males may be at greater risk for HIV infection among
this group of substance users. In fact, research has sug-
gested that male to female transmission is significantly
more effective than female to male transmission, thus
putting females at greater risk for infection. Specifically,
the estimated transmission rate in male partners of in-
fected women ranges from 1% [35] to 12%, [36] while
the estimated transmission rate of female partners of in-
fected men is approximately 20% [35,36]. In other words,
male to female HIV transmission is approximately two
times as efficient than female to male transmission. In a
longitudinal study of unsafe sex among HIV infected
adults, sex-risk behavior did not increase among women
with steady partners but, the frequency of sex-risk be-
havior doubled among heterosexual men with steady
partners over the study period [37]. Further, female drug
users may be especially vulnerable to th e transmission of
HIV through sex, as their sexual networks tend to be lar-
ger, have more networks that provide financial support
[25], and have more overlap between members than men
[38,39]. In addition, among African American female
crack users, engaging in sex trade [40] and having social
networks that use heroin or cocaine is associated with
HIV infection [25]. This is particularly concerning given
that nationally, Black females have the greatest propor-
tion of new HIV/AIDS cases by sex; 67.2% [41].
Risk factors for heterosexual transmission of HIV in-
clude inconsistent condom use, sexual contact during
menses, anal sex, and age of female partner [42]. One
explanation for HIV transmission via sexual routes
among NIDUs is that intoxication through the use of
various substances may lead to a lack of attention to en-
gaging in the practice of safe sex or a propensity toward
engaging in high-risk sex [19,43]. In a study of serodis-
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Prevalence of Human Immunodeficiency Virus (HIV), Risk Behavior, and Recent Substance Use in a
Sample of Urban Drug Users: Findings by Race and Sex 191
cordant couples, those who reported recent substance use
were over two times as likely to have had unprotected
sexual episodes than couples where both partners did not
report recent substance use. In addition, drug dependent
partners were three and half times more likely to engage
in recent unprotected sexual episodes than in couples
where neither partner was drug dependent [44]. Taken
together, these studies show that substance use in general
increases the likelihood of sex-risk behaviors, thereby
allowing for the possibility of HIV and other STD trans-
mission through unprotected sex. Interventions that focus
on high-risk sexual behaviors associated with drug use
are needed to reduce the risk of HIV transmission among
vulnerabl e po p ul at ions [21,45 ] .
Despite the contributions of the current study, there are
limitations in the current research that are inherent in a
cross-sectional design. Namely, while cross-sectional
research is a vital tool in identifying areas for more in-
depth study, the ability to make causal inferences must
be reserved for experimental studies. Further, these find-
ings possess limited generalizability to larger, non-illicit
drug using populations in non-urban areas. Finally, this
study uses retrospective data where there is reliance on
the self-report of drug use history, however, self-report
of drug use has been demonstrated as a reliable and valid
method of describing drug use [46]. In this study urinaly-
sis data is consistent with self-report findings.
5. Conclusion
Notwithstanding limitations discussed above, this study
has several inherent strengths. To our knowledge, it is the
only study to examine substance use, sex-risk behavior,
and HIV simultaneously by race and sex among a large
sample of both IDUs and NIDUs. Findings presented
here have several important implications for HIV pre-
vention and care among substance users. The National
Survey on Drug Use and Health reports that approxi-
mately 25% of individuals diagnosed with HIV/AIDS are
in need of alcohol or other illicit drug use treatment [47].
Intervention programs that incorporate substance use
treatment in addition to HIV education, particularly with
respect to substance use and sex-risk behavior are im-
perative. Research has noted a need for multidisciplinary
approaches to treatment specifically designed for sub-
stance users infected with HIV [48,49]. Multidisciplinary
approaches incorporate medical, psychiatric, and sub-
stance use treatment [50]. This type of treatment ap-
proach may be particularly important for reducing sex-
risk behavior among groups at high risk for HIV trans-
mission. In fact, several intervention studies have noted
some success in reducing sex-risk behavior among sub-
stance users [50-53]. Although these studies present
promising results, more research is needed to identify
causes of this racial disparity, so that interven tio ns can be
developed to reduce the rates of HIV infection in African
Americans. There is a need for expansion of this type of
treatment to high-risk groups in urban environments as
HIV-positive substance users present a significant public
health concern. REFERENCES
[1] O. C. Nwanyanwu, S. Y. Chu, T. A. Green, J. W. Buehler
and R. L. Berkelman, “Acquired-Immunodeficiency-Syn-
drome in the United-States Associated with Injecting
Drug-Use, 1981-1991,” The American Journal of Drug
and Alcohol Abuse, Vol. 19, No. 4, 1993, pp. 399-408.
[2] D. C. Des Jarlais, S. R. Friedman and W. Hopkins, “Risk
Reduction for the Acquired Immunodeficiency Syndrome
among Intravenous Drug Users,” Annals of Internal Me-
dicine, Vol. 103, No. 5, 1985, pp. 755-759.
[3] R. E. Chaisson, A. R. Moss, R. Onishi, D. Osmond and J.
R. Carlson, “Human Immunodeficiency Virus Infection in
Heterosexual Intravenous Drug Users in San Francisco,”
American Journal of Public Health, Vol. 77, No. 2, 1987,
pp. 169-172. doi:10.2105/AJPH.77.2.169
[4] E. E. Schoenbaum, D. Hartel, P. A. Selwyn, et al., “Risk
Factors for Human Immunodeficiency Virus Infection in
Intravenous Drug Users,” The New England Journal of
Medicine, Vol. 321, No. 13, 1989, pp. 874-879.
[5] E. J. van Ameijden and R. A. Coutinho, “Maximum Im-
pact of HIV Prevention Measures Targeted at Injecting
Drug Users,” AIDS, Vol. 12, No. 6, 1998, pp. 625-633.
[6] R. Marx, S. O. Aral, R. T. Rolfs, C. E. Sterk and J. G.
Kahn, “Crack, Sex, and STD,” Sexually Transmitted Dis-
eases, Vol. 18, No. 2, 1991, pp. 92-101.
[7] R. J. Battjes, R. W. Pickens, Z. Amsel and L. S. Brown
Jr., “Heterosexual Transmission of Human Immunodefi-
ciency Virus among Intravenous Drug Users,” The Jour-
nal of Infectious Diseases, Vol. 162, No. 5, 1990, pp.
1007-1011. doi:10.1093/infdis/162.5.1007
[8] I. H. Meyer and L. Dean, “Patterns of Sexual Behavior
and Risk Taking among Young New York City Gay
Men,” AIDS Education and Prevention, Vol. 7, Supple-
ment 5, 1995, pp. 13-23.
[9] R. B. Hays, S. M. Kegeles and T. J. Coates, “High HIV
Risk-Taking among Young Gay Men,” AIDS, Vol. 4, No.
9, 1990, pp. 901-907.
[10] G. F. Lemp, A. M. Hirozawa, D. Givertz, et al., “Sero-
prevalence of HIV and Risk Behaviors among Young
Homosexual and Bisexual Men. The San Francisco/
Berkeley Young Men’s Survey,” The Journal of the
American Medical Association, Vol. 272, No. 6, 1994, pp.
449-454. doi:10.1001/jama.1994.03520060049031
[11] D. H. Osmond, K. Page, J. Wiley, et al., “HIV Infection
in Homosexual and Bisexual Men 18 to 29 Years of Age:
The San Francisco Young Men’s Health Study,” Ameri-
Copyright © 2012 SciRes. WJA
Prevalence of Human Immunodeficiency Virus (HIV), Risk Behavior, and Recent Substance Use in a
Sample of Urban Drug Users: Findings by Race and Sex
can Journal of Public Health, Vol. 84, No. 12, 1994, pp.
1933-1937. doi:10.2105/AJPH.84.12.1933
[12] J. Ruiz, M. Facer and R. K. Sun, “Risk Factors for Hu-
man Immunodeficiency Virus Infection and Unprotected
Anal Intercourse among Young Men Who Have Sex with
Men,” Sexually Transmitted Diseases, Vol. 25, No. 2,
1998, pp. 100-107.
[13] G. R. Seage III, K. H. Mayer, W. R. Lenderking, et al.,
“HIV and Hepatitis B Infection and Risk Behavior in
Young Gay and Bisexual Men,” Public Health Reports,
Vol. 112, No. 2, 1997, pp. 158-167.
[14] SAMHSA, “The NSDUH Report: HIV/AIDS and Sub-
stance Use,” Rockville, 2010.
[15] Hygiene DoHaM, “Maryland Vital Statistics Annual Re-
port,” 2009.
[16] Hygiene MDoHaM, “Baltimore City HIV/AIDS Statistics
Fact Sheet,” 2008.
[17] SAMHSA, “National Survey on Drug Use and Health,”
[18] Enters for Disease Control and Prevention (CDC; 2008).
Estimates of New HIV Infections in the United States.
[19] S. A. Strathdee and S. G. Sherman, “The Role of Sexual
Transmission of HIV Infection among Injection and
Non-Injection Drug Users,” Journal of Urban Health,
Vol. 80, Suppl. 3, 2003, pp. 7-14.
[20] I. Kuo, A. E. Greenberg, M. Magnus, et al., “High Preva-
lence of Substance Use among Heterosexuals Living in
Communities with High Rates of AIDS and Poverty in
Washington, DC,” Drug and Alcohol Dependence, 2011.
[21] L. Degenhardt, B. Mathers, P. Vickerman, T. Rhodes, C.
Latkin and M. Hickman, “HIV in People Who Use Drugs
2 Prevention of HIV Infection for People Who Inject
Drugs: Why Individual, Structural, and Combination Ap-
proaches Are Needed,” The Lancet, Vol. 376, No. 9737,
2010, pp. 285-301.
[22] E. Volz, S. D. Frost, R. Rothenberg and L. A. Meyers,
“Epidemiological Bridging by Injection Drug Use Drives
an Early Hiv Epidemic,” Epidemics, Vol. 2, No. 3, 2010,
pp. 155-164. doi:10.1016/j.epidem.2010.06.003
[23] A. Neaigus, S. R. Friedman, B. J. Kottiri and D. C. D.
Jarlais, “HIV Risk Networks and HIV Transmission
among Injecting Drug Users,” Evaluation and Program
Planning, Vol. 24, No. 2, 2001, pp. 221-226.
[24] D. J. Pilowsky, D. Hoover, B. Hadden, et al., “Impact of
Social Network Characteristics on High-Risk Sexual Be-
haviors among Non-Injection Drug Users,” Substance
Use & Misuse, Vol. 42, No. 11, 2007, pp. 1629-1649.
[25] R. C. Neblett, M. Davey-Rothwell, G. Chander and C. A.
Latkin, “Social Network Characteristics and HIV Sexual
Risk Behavior among Urban African American Women,”
Journal of Urban Health, Vol. 88, No. 1, 2011, pp. 54-65.
[26] US Census Bureau, Maryland State Census, 2010.
[27] D. Vlahov, J. C. Anthony, A. Munoz, et al., “The ALIVE
Study, a Longitudinal Study of HIV-1 Infection in Intra-
venous Drug Users: Description of Methods and Charac-
teristics of Participants,” NIDA Research Monograph,
Vol. 109, 1991, pp. 75-100.
[28] M. M. Mitchell and W. W. Latimer, “Unprotected Casual
Sex and Perceived Risk of Contracting HIV among Drug
Users in Baltimore, Maryland: Evaluating the Influence
of Non-Injection versus Injection Drug User Status,”
AIDS Care, Vol. 21, No. 2, 2009, pp. 221-230.
[29] J. Pallant, “SPSS Survival Manual,” McGraw-Hill, New
York, 2007.
[30] SPSS, PASW Statistics 17, SPSS Inc., Chicago, 2009.
[31] D. C. Des Jarlais, K. Arasteh and S. R. Friedman, “HIV
among Drug Users at Beth Israel Medical Center, New
York City, the First 25 Years,” Substance Use & Misuse,
Vol. 46, No. 2-3, 2011, pp. 131-139.
[32] CDC CfDC, “Update to Racial/Ethnic Disparities in Di-
agnoses of HIV/AIDS-33 States, 2001-2005,” Center for
Disease Control and Prevention, 2007.
[33] C. Latkin, W. Mandell, M. Oziemkowska, et al., “Using
Social Network Analysis to Study Patterns of Drug-Use
among Urban Drug-Users at High-Risk for HIV-AIDS,”
Drug and Alcohol Dependence, Vol. 38, No. 1, 1995, pp.
1-9. doi:10.1016/0376-8716(94)01082-V
[34] C. A. Latkin, S. J. Kuramoto, M. A. Davey-Rothwell and
K. E. Tobin, “Social Norms, Social Networks, and HIV
Risk Behavior among Injection Drug Users,” AIDS and
Behavior, Vol. 14, No. 5, 2010, pp. 1159-1168.
[35] N. S. Padian, S. C. Shiboski and N. P. Jewell, “Female-
to-Male Transmission of Human-Immunodeficiency-Vi-
rus,” The Journal of the American Medical Association,
Vol. 266, No. 12, 1991, pp. 1664-1667.
[36] I. Devincenzi, R. A. Ancellepark, J. B. Brunet, et al.,
“Comparison of Female to Male and Male to Female
Transmission of HIV in 563 Stable Couples,” British
Medical Journal, Vol. 304, No. 6830, 1992, pp. 809-813.
[37] R. Seng, M. Rolland, G. Beck-Wirth, et al., “Trends in
Unsafe Sex and Influence of Viral Load among Patients
Followed Since Primary HIV Infection, 2000 to 2009,”
AIDS, 2011.
[38] M. Miller and A. Neaigus, “Sex Partner Support, Drug
Use and Sex Risk among HIV-Negative Non-Injecting
Heroin Users,” AIDS Care, Vol. 14, No. 6, 2002, pp.
801-813. doi:10.1080/0954012021000031877
[39] S. B. Montgomery, J. Hyde, C. J. De Rosa, et al., “Gen-
der Differences in HIV Risk Behaviors among Young In-
jectors and Their Social Network Members,” The Ameri-
can Journal of Drug and Alcohol Abuse, Vol. 28, No. 3,
2002, pp. 453-475. doi:10.1081/ADA-120006736
[40] M. Miller, C. T. Korves and T. Fernandez, “The Social
Copyright © 2012 SciRes. WJA
Prevalence of Human Immunodeficiency Virus (HIV), Risk Behavior, and Recent Substance Use in a
Sample of Urban Drug Users: Findings by Race and Sex
Copyright © 2012 SciRes. WJA
Epidemiology of HIV Transmission among African
American Women Who Use Drugs and Their Social Net-
work Members,” AIDS Care-Psychological and Socio-
Medical Aspects of AIDS/HIV, Vol. 19, No. 7, 2007, pp.
[41] Control CfD, “Update to Racial/Ethnic Disparities in
Diagnoses of HIV/AIDS-33 States, 2001-2005,” 2007.
[42] I. Devincenzi, “Heterosexual Transmission of HIV,” The
Journal of the American Medical Association, Vol. 267,
No. 14, 1992, pp. 1909-1919.
[43] D. Castor, D. J. Pilowsky, B. Hadden, et al., “Sexual Risk
Reduction among Non-Injection Drug Users: Report of a
Randomized Controlled Trial,” AIDS Care-Psychological
and Socio-Medical Aspects of AIDS/HIV, Vol. 22, No. 1,
2010, pp. 62-70.
[44] Group NMHSPTfAAC, “The Contribution of Male and
Female Partners’ Substance Use to Sexual Risks and
STDs among African American HIV Serodiscordant Cou-
ples,” AIDS and Behavior, Vol. 14, No. 5, 2010, pp.
1045-1054. doi:10.1007/s10461-010-9695-y
[45] D. L. Jones, D. Waldrop-Valverde, P. Gonzalez, et al.,
“Mental Health in HIV Seronegative and Seropositive
IDUs in South Florida,” AIDS Care, Vol. 22, No. 2, 2010,
pp. 152-158. doi:10.1080/09540120903039851
[46] S. Darke, “Self-Report among Injecting Drug Users: A
review,” Drug and Alcohol Dependence, Vol. 51, No. 3,
1998, pp. 253-263. doi:10.1016/S0376-8716(98)00028-3
[47] SAMHSA, “HIV/AIDS and Substance Use,” 2010.
[48] F. L. Altice, A. Kamarulzaman, V. V. Soriano, M. Sche-
chter and G. H. Friedland, “Treatment of Medical, Psy-
chiatric, and Substance-Use Comorbidities in People In-
fected with HIV Who Use Drugs,” The Lancet, Vol. 376,
No. 9738, 2010, pp. 367-387.
[49] M. S. Friedman, M. P. Marshal, R. Sta ll, et al., “Associa-
tions between Substance Use, Sexual Risk Taking and
HIV Treatment Adherence among Homeless People Liv-
ing with HIV,” AIDS Care, Vol. 21, No. 6, 2009, pp.
692-700. doi:10.1080/09540120802513709
[50] L. N. Drumright and G. N. Colfax, “HIV Risk and Pre-
vention for Non-Injection Substance Users, in HIV Pre-
vention: A Comprehensive Approach,” Academic Press,
Burlington, 2009.
[51] S. Magura, S. Y. Kang and J. L. Shapiro, “Outcomes of
Intensive AIDS Education for Male Adolescent Drug Us-
ers in Jail,” Journal of Adolescent Health, Vol. 15, No. 6,
1994, pp. 457-463. doi:10.1016/1054-139X(94)90492-L
[52] J. S. Lawrence, R. A. Crosby, T. L. Brasfield and R. E.
O’Bannon III, “Reducing STD and HIV Risk Behavior of
Substance-Dependent Adolescents: A Randomized Con-
trolled Trial,” Journal of Consulting and Clinical Psy-
chology, Vol. 70, No. 4, 2002, pp. 1010-1021.
[53] W. M. Wechsberg, W. K. Luseno, R. S. Karg, et al., “Al-
cohol, Cannabis, and Methamphetamine Use and Other
Risk Behaviours among Black and Coloured South Afri-
can Women: A Small Randomized Trial in the Western
Cape,” International Journal of Drug Policy, Vol. 19, No.
2, 2008, pp. 130-139. doi:10.1016/j.drugpo.2007.11.018