The National AIDS Demonstration Research (NADR) Program of the National Institute on Drug Abuse evaluates community-based outreach and prevention efforts targeted to injecting-drug users (IDUs) and their sex partners. These sex partners who are not IDUs are at substantial risk for human immunodeficiency virus (HIV) infection, particularly if they engage in sexual intercourse without using condoms. In 1990, 1531 of the 42,557 acquired immunodeficiency syndrome (AIDS) cases reported to CDC occurred among sex partners of IDUs, an increase of nearly 32% from 1989 (1). This report summarizes data from the NADR Program characterizing persons who self-reported never having injected drugs themselves but having had sex with a partner who was an IDU.

From June 1988 through March 1991, female and male sex partners of IDUs were recruited through community-based outreach settings (including door-to-door, hospital emergency rooms and clinics, and social service programs). Female sex partners of IDUs were interviewed at 54 sites throughout the United States (including Puerto Rico); male sex partners were recruited at 45 sites. The participants were interviewed using the AIDS Initial Assessment questionnaire to collect baseline information on demographics, sex and drug-use practices, and knowledge and attitudes about AIDS. In most sites, participants were given cash payments of $10-$20 or other material incentives (e.g., transportation vouchers, restaurant coupons) for completing an interview (2). The percentages given in this report are estimates obtained from a nonrandom sample of sex partners; therefore, the actual percentages could be different.

Of the 6104 study participants, 4249 (70%) were female; 1651 (27%) resided in the Northeast, 843 (14%) in the Midwest, 1670 (27%) in the South, 1490 (24%) in the West, and 450 (7%) in Puerto Rico. Of the females, 2474 (58%) were black and 1148 (27%) were Hispanic; of the males, 1291 (70%) were black and 241 (13%) were Hispanic. Most study participants (3834 (90%) females and 1438 (78%) males) were less than or equal to 40 years of age (median: for females, 28.7 years (range: 13-73 years); for males, 31.8 years (range: 15-69 years)).

Among the study participants, 2263 (53%) females and 1196 (64%) males had completed high school. Four hundred twenty-six (10%) females and 377 (20%) males reported full-time employment; 2155 (51%) females and 739 (40%) males were unemployed. In addition, 534 (13%) females and 369 (20%) males reported living either in a shelter or on the streets. Those reporting having been in jail or prison at some time during their lives included 1548 (36%) females and 1250 (67%) males.

Although none of these sex partners reported having injected drugs, many reported use of noninjected drugs during the 6 months before the interview (Table 1). For example, 52% of the females and 58% of the males used cocaine in some form other than by injection. However, 976 (23%) females and 505 (27%) males reported ever having been in drug treatment during their lives; 843 (20%) females and 480 (26%) males reported participating in such groups during the 6 months before the interview.

Most study participants (76% of females and 60% of males) reported having had heterosexual sex during the past 6 months with only one IDU partner (Figure 1); fewer participants (9% of females and 11% of males) reported having had sex with five or more IDU partners during that period. In comparison, 52% of female and 25% of male participants reported having a total of one heterosexual partner during the past 6 months (Figure 2), and 18% of female and 28% of male participants reported a total of five or more sex partners. Among the female study participants, 5% reported sex with a female partner who had injected drugs (2% strictly homosexual, 3% bisexual); among the males, 9% reported sex with a male IDU who was currently injecting drugs (5% strictly homosexual, 4% bisexual).

Although all of these sex partners of IDUs were at risk for acquiring HIV infection, latex condom use was uncommon (Table 2). Condoms were used less frequently by those with one IDU partner than by those with multiple partners: among females and males with one IDU partner, 30% and 38%, respectively, reported sometimes or always using condoms; among those with five or more partners, 72% of females and 47% of males reported sometimes or always using condoms.

For both females and males, vaginal intercourse was the most frequently reported sexual activity: 97% of females and 94% of males had vaginal sex during the 6 months before the interview (Table 2). Anal intercourse was less frequent: among the males, 22% reported anal sex with a female partner; 7% of the males reported insertive anal sex with a male partner, and 4% reported receptive anal sex. Always using condoms was infrequently reported for all types of sexual activity (Table 2).

Of all study participants, 1077 (25%) females and 396 (21%) males reported trading sex for drugs and/or money during the 6 months before the interview. Among females, 611 (14%) reported trading sex for drugs and 1021 (24%) for money; among males, 238 (13%) reported trading sex for drugs and 270 (15%) for money. Reported by: G Weissman, MA, Div of HIV Svcs, Health Resources and Svcs Administration. VB Brown, PhD, Prototypes-Women AIDS Risk Network, Culver City, California. The National AIDS Research Consortium: M Andersen, PhD, R Baxter, MEd, S Baxter, P Biernacki, PhD, S Broadnax, MD, BS Brown, PhD, W Davis, L DeNeal, PhD, S Deren, PhD, A Estrada, PhD, P Evans, MD, H Feldman, PhD, D Fleming, MD, J French, PhD, S Friedman, PhD, S Gates, P Glider, PhD, A Green, PhD, M Gross, PhD, T Hammett, PhD, D Hunt, PhD, AB Jones, J Keyser-Smith, L Kotransky, PhD, A Kroliczak, PhD, K Lewis, S Margolis, PhD, C McCoy, PhD, V McCoy, PhD, J Mondanaro, MD, H Musikoff, PhD, R Needle, PhD, V Rachel, PhD, F Rhodes, PhD, R Robles, PhD, R Ross, B Rounsaville, MD, R Rucker, PhD, J Schensul, PhD, V Shorty, H Siegal, PhD, M Singer, PhD, C Singh, PhD, F Snyder, PhD, K South, R Stephens, PhD, S Stevens, PhD, K Vogtsberger, MD, J Walton, D Watson, MS, W Wiebel, PhD, M Williams, PhD, R Wood, MD. Office of the Deputy Director (HIV), National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: In 1990, nearly two thirds the females and half the males who had contracted AIDS through heterosexual activity had had a sex partner who was an IDU (1). Findings from the NADR Program indicate that sex partners of IDUs--a population considered to be "hard to reach"--can be accessed through community-based recruitment strategies that are selectively targeted. Evaluation of NADR Program projects indicates that many sex partners of IDUs either distrust or are unable to use the services of medical and social service providers. Accordingly, to be effective, outreach programs must deliver prevention programs directly to those at risk--where they live, work, and socialize. A key element in this program is the training and use of outreach staff who can be trusted by and are able to communicate with the target population (3-5).

Because the findings in this study are based on a nonrandom sample of sex partners of IDUs, they cannot be generalized. Nonetheless, the findings suggest the need for additional methods for reaching sex partners of IDUs. For example, drug-treatment programs could intensify efforts to reach partners of their IDU clients by making use of extensive staff training in HIV issues, innovative outreach methods, and creative counseling strategies. The findings also underscore the need to further refine methods of access that are tailored to specific groups, including those who are incarcerated, homeless, or unemployed; have low education levels; or are members of racial/ethnic minorities.

Among persons interviewed in this study, noninjecting-drug use was common. Many noninjected drugs, including alcohol, impair judgment and potentially increase HIV risk behaviors (6); the use of crack cocaine in particular increases risky sexual behavior, especially among females (7,8). In addition, active drug use constrains maintenance of positive behavior changes (3-6). Thus, AIDS prevention messages and interventions need to emphasize the risks involved with the use of both noninjected and injected drugs.

Condom use was more frequently reported by participants with multiple than single IDU sex partners, suggesting that 1) persons with multiple partners may be making a greater effort and/or finding it easier to protect themselves with some partners and/or 2) persons with only one partner believe, erroneously, they are not at risk for heterosexual transmission of HIV. Based on these findings, prevention messages for IDUs must emphasize the importance of both reducing the number of (known or suspected) IDU partners, and using latex condoms during every sexual contact by those with a single partner and those with multiple partners.

References

1. CDC. HIV/AIDS surveillance report: year-end edition. Atlanta: US Department of Health and Human Services, Public Health Service, 1991:9.

2. CDC. Update: reducing HIV transmission in intravenous-drug users not in drug treatment--United States. MMWR 1990;39:529,535-8.

3. Cohen J, Hauer L, Wofsy C. Women and IV drugs: parenteral and heterosexual transmission of human immunodeficiency virus. Journal of Drug Issues 1989;19:39-56.

4. Rosenshine N, Sowder B, Weissman G, Young PL. AIDS prevention model: reaching women at risk. Bethesda, Maryland: NOVA Research Company, 1990.

5. Weissman G, the National AIDS Research Consortium. AIDS prevention for women at risk: experience from a national demonstration research program. Journal of Primary Prevention 1991;12:49-63.

6. Mondanaro J. Strategies for AIDS prevention: motivating health behavior in drug dependent women. J Psychoactive Drugs 1987;19:143-9.

7. Weissman G, Sowder B, Young P, the National AIDS Research Consortium. The relationship between crack cocaine use and other risk factors among women in a national AIDS prevention program (Abstract). Vol 3. VI International AIDS Conference. San Francisco, June 20-24, 1990:126.

8. Fullilove RE, Fullilove MT, Bowser BP, Gross SA. Risk of sexually transmitted disease among black adolescent crack users in Oakland and San Francisco, Calif. JAMA 1990;263:851-5.

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