Sexually Transmitted Diseases:
Sex, Drugs, and Infections Among Youth: Parenterally and Sexually Transmitted Diseases in a High‐Risk Neighborhood
FRIEDMAN, SAMUEL R. PhD*; CURTIS, RICHARD PhD*; JOSE, BENNY PhD*; NEAIGUS, ALAN PhD*; ZENILMAN, JONATHAN MD†; CULPEPPER‐MORGAN, JOAN MD‡§; BORG, LISA MD‡; KREEK, MARY JEANNE MD‡; PAONE, DENISE EdD∥; JARLAIS, DON C.DES PhD*∥
*From the National Development and Research Institutes, New York, New York, †Infectious Diseases, Medicine, Johns Hopkins University, Baltimore, Maryland, ‡Biology of Addictive Diseases Laboratory, Rockefeller University, New York, New York, §Norwalk Hospital, Norwalk, Connecticut, and ∥Chemical Dependency Institute, Beth Israel Medical Center, New York, New York
The authors thank Thomas P. Ward for editorial assistance.
Supported by grants R01 A134723 from the National Institute of Allergy and Infectious Diseases on “HIV Risk among Youth”; R01 DA10411 from the National Institute on Drug Abuse on “Drug Use and HIV Risk among Youth”; P50 DA05130 “Research Center‐Biological Correlates of the Treatment of Addiction” (MJK, JCM, LB); and K05 DA00049 “Research Scientist Award” (MJK).
Reprint requests: Samuel R. Friedman, PhD, National Development and Research Institutes, Two World Trade Center, 16th Floor, New York, NY 10048.
Received for publication August 21, 1996, revised January 14, 1997, and accepted January 17, 1997.
Background and Objectives:: To determine the extent to which youth who reside in households in a neighborhood with large numbers of drug injectors 1) are infected with parenterally or sexually transmitted agents, and 2) engage in high‐risk behaviors.
Study Design:: A multistage probability household sample survey was conducted in Bushwick, Brooklyn from 1994 to 1995. All households in 12 randomly selected primary sampling units were screened for age‐eligible youth. One hundred eleven English‐speaking 18‐ to 21‐year‐olds were interviewed. One hundred three sera were tested for human immunodeficiency virus type 1 (HIV‐1), hepatitis B virus, hepatitus C virus (HCV), human T‐cell lymphotrophic virus types I and II (HTLV‐I/II), herpes simplex virus type 2 (HSV‐2), or syphilis. Urines were tested for chlamydial infection, and for opiate and cocaine metabolites.
Results:: Eighty‐nine percent had sex in the past year, 45% with two or more partners. Only 19% of the sexually active always used condoms. Two (of 95) had had sex with a crack smoker. Thirty percent of women reported being coerced the first time they had sex, and 23% of women and 3% of men reported having been sexually abused. Only 3% reported ever using heroin, and 9% cocaine. Only one reported ever having injected drugs or smoked crack. Some underreporting of stigmatized behaviors occurred: two “nonreporters” had opiatepositive urines and two had cocaine‐positive urines. Marijuana use was common, with 48% using it in the past year. No subjects tested positive for HIV‐1, HTLV‐II, or syphilis; 2% tested positive for HTLV‐I and 3% for hepatitis C; 3% had hepatitis B markers, 12% had chlamydial infection, and 50% serologic HSV‐2 markers.
Conclusions:: Population‐representative samples of high‐risk communities can provide important knowledge. Although heroin and cocaine use, drug injection, and rates of infection with parenterally transmitted infectious agents appear to be lower among these youth, sexual risk behaviors and chlamydial and HSV‐2 infection are widespread. Sexually transmitted disease screening and outreach strategies are needed both to prevent sexually transmitted disease sequelae (including potential increased susceptibility to HIV infection) and to prevent transmission to partners.
NEIGHBORHOODS THAT CONTAIN large numbers of drug injectors and crack smokers are potential settings for widespread sexual transmission of many infections, including human immunodeficiency virus (HIV), to local youth.1–3 Because many youth experiment with risky behaviors, the easy availability of heroin and cocaine in such neighborhoods may attract local youth to use these drugs, and, as a consequence, to engage in high‐risk injection or unprotected sex with drug injectors or their sexual networks.
This primarily descriptive article reports on levels of drug use, sexual behavior, and parenterally and sexually transmitted infections in a probability sample of house‐hold youth in such a high‐risk neighborhood.
Bushwick is a Brooklyn, New York, community of 100,000 population. Its residents are primarily low‐income Latinos and African Americans. It has been a major area for drug sales and drug injection. Over 40% of the drug injectors in Bushwick are HIV‐1‐infected,4 and over 70% of drug injectors in Bushwick5 and elsewhere in New York6 show evidence of having been infected with hepatitis B.
A multistage probability sample of English‐speaking 18‐ to 21‐year‐olds was recruited in Bushwick in 1994 to 1995 from 12 primary sampling units, each of which was a pair of adjacent face‐blocks. The primary sampling units were randomly selected from a listing of all such adjacent face‐blocks in Bushwick (details available from senior author). All households in each of the 12 selected primary sampling units were screened to locate those containing age‐eligible youth. In each household with any age‐eligible youth, one youth was randomly selected to be interviewed and to give blood and urine specimens with informed consent. The consent process included a description of the questionnaire and of the tests for infectious agents. Participants were reimbursed with a small fee ($20) at completion of the interview, and another $20 after pretest counseling, in recognition of their time and effort. From 129 selected youth, 111 (86%) were interviewed, and 104 (81%) specimens were obtained. Failures to obtain interviews were due either to refusals or to inability to arrange a time for the interview before the study (which, as a pilot study, had very limited funding) had to cease field operations. Seven youth declined to provide specimens either after pretest counseling or because of difficulty in drawing blood. The distribution on race/ethnicity and gender of these English‐speaking youth (plus an additional 11 non‐English‐speaking youth who were interviewed with a short questionnaire in Spanish, but who were not included in the analyses for this article) was similar to those from U.S. Census data, which report that, of Bushwick youth aged 18 to 21 years, 29% are black, 67% Hispanic, and 52% are women; the sample proportions were essentially the same, 28%, 67%, and 51%, respectively.
Interviews and specimen collection were conducted in private settings, either in participants' homes or in a project storefront. In no case were interviews conducted where anyone besides the interviewer and the participant could hear the questions and answers.
Sera were tested for HIV‐1 (Genetic Systems [Redmond, WA] enzyme‐linked immunosorbent assay; positive results were confirmed with Western blot [Bio‐Rad Laboratories, Hercules, CA]), hepatitis C antibody, hepatitis B core antibody, human T‐cell lymphotrophic virus type I (HTLV‐I) and type II (HTLV‐II; all using enzyme immunoassay tests; Abbott Laboratories, Abbott Park, IL). Subjects who were positive for hepatitis B core antibody were tested for surface antigen by neutralization (Abbott Laboratories). Syphilis serology was determined by rapid plasma reagin (Becton‐Dickinson, Sparks, MD) and confirmed by fluorescent treponemal antibody. All commercially available tests were performed in accordance with quality control procedures recommended by the manufacturer and licensing agencies. Herpes simplex virus type 2 (HSV‐2) serology was performed by Western blot as previously described.7
Urines were tested for chlamydial infection by Abbott ligase chain reaction.8,9 Eighty‐seven remainder urines were tested for opiate and cocaine metabolites (EMIT; Syva, San Jose, CA); these tests detect recent drug use. Because the decision to test remainder urines was made after subject identifiers had been unlinked from the data, informed consent could not be obtained.
When subjects returned for their test results, they were given appropriate counseling and referrals.
Five focus groups, recruited from a variety of high‐ and low‐risk local youth, were conducted before data collection as part of the process of designing the questionnaire and sampling procedures. The groups were chosen to have different gender and racial/ethnic compositions, and to differ in terms of their personal interests and activities. The groups varied in attendance from 3 to 15 youth. The focus groups also elicited descriptions and discussions of how local youth perceive and differentiate drug‐using and sexual behaviors.
Of 111 youth, 48% (53) were women; 65% (72) were Latino and 31% (34) African American; and 41% (46) were neither employed nor attending school.
As shown in Table 1, none of the youth shows serologic evidence of infection with HIV‐1, HTLV‐II, or syphilis (although the tests do not rule out the possibility of successful syphilis treatment and seroreversion). Two percent (2/103) tested positive for HTLV‐I, and 3% (3/103) for hepatitis C; 3% (3/103) have indicators of prior infection with hepatitis B, and 50% (51/102) with HSV‐2. Women (64%) were more likely than men (37%; p = 0.006) to be infected with HSV‐2. Although there was some tendency for older participants to be more likely to be infected with HSV‐2 (58% of 20‐ and 21‐year‐olds vs. 45% of 18‐ and 19‐year‐olds), this was not statistically significant (p = 0.22); nor was significance obtained within either the male or female subset. Twelve percent (8/64) have chlamydial infection, but the apparent gender difference (men 19%, women 6%) fails to approach statistical significance (p > 0.2).
Subjects report considerable sexual risk: 89% (99) had had sex in the last year, and 45% (50) had sex with two or more partners; neither of these proportions varied significantly by gender. Only 19% (19/99) of those who had had sex always used condoms, and this did not vary significantly by gender. None had ever knowingly had sex with a drug injector, and only 2% (2/95; including one woman) had ever had sex with a crack smoker. Fifty‐eight percent (30/52) of the women had been pregnant. No men but two women reported having had same‐sex sex in the past 30 days. Some sex was involuntary: 30% (14/47) of women report they were coerced the first time they had sex, and 23% (12/52) of women and 3% (2/58) of men report having been victims of sex abuse. (Note that some totals add up to less than 111 if one or more respondents did not answer a given question.)
Although 18% (20/109) have engaged in selling cocaine or heroin at some time in their lives, only 3 of 111 subjects (3%) reported ever using heroin and 10 (9%) reported ever using cocaine. Male participants were more likely to have sold cocaine or heroin (26% vs. 10%; P = 0.024), but gender differences in heroin use (3% of men, 2% of women) and cocaine use (7% of men, 11% of women) were not significant. Only one subject reported having ever injected drugs or smoked crack; she had done both. Some underreporting of recent drug use was documented: 2 of 85 “nonreporters” with available data had opiate‐positive urines and 2 of 80 “nonreporters” with available data had cocaine‐positive urines. Even with these additions, an unexpectedly low 5 (6%) had evidence of any heroin use, and only 12 (11%) of cocaine use. Possible additional underreporting of risk behaviors is suggested by the fact that none of the three participants who tested positive for hepatitis C virus reported ever having injected drugs (or using heroin or cocaine), and two of them (both women) denied ever having had sex.
The youths seem to distinguish heroin use, cocaine use, and drug injection from marijuana use. Fully 63% (71% of men, 55% of women; p = 0.082) have smoked marijuana (48% in the past year, including 53% of men and 42% of women; p > 0.2), and there was little underreporting of marijuana use (only 1 of 31 subjects whose urine was analyzed and who denied using marijuana tested positive for marijuana). In all five of the focus groups, participants were unanimous in their opinion that their peers would be ashamed of using heroin or cocaine. When asked where people their age might use heroin or cocaine, one focus group participant said: “Hiding some‐where on the down low; probably in the bathroom. Only the old‐timers do those things where others can see them.” By contrast, most focus group participants said that they did not consider marijuana or alcohol to be drugs, and that indeed the use of these substances was status enhancing among their peers rather than stigmatizing. Although focus group participants consistently estimated that the percentage of local youth using cocaine, crack, or heroin was below 5%, the estimated percentage of youth smoking marijuana was reported to be above 90%. As one participant remarked, “Everyone thinks that smoking weed and drinking beer is cool.”
Budgetary restrictions limited the number of primary sampling units and of participants, and also limited these analyses to youth who spoke enough English to be interviewed. Youth who do not live in households were not included. Homeless youth‐of whom there are few in this neighborhood‐or the approximately 20% of non‐English‐speaking youth in the neighborhood may be at higher behavioral risk and may be more likely to be infected with these agents. The data may underreport heroin and cocaine use because the urine tests for drug metabolites detect only recent use. Research is needed on the generalizability of these results to other, similar neighborhoods and to youth who are older, non‐English‐speaking, or homeless. Missing data due to difficulties in transmitting and storing samples might limit the accuracy of the estimated prevalence of chlamydial infection.
The modest sample size in this study does not preclude the possibility that there may be substantial heroin use, drug injection, or HIV infection among other or older household youths or young adults in Bushwick. The 95% upper bound on HIV seroprevalence, for example, is almost 5%. The findings here also do not preclude the possibility that heroin and cocaine use, drug injection, and HIV infection may increase (or decrease) among these subjects as they grow older, or that historical developments (e.g, increased socioeconomic marginalization of youth in high‐risk neighborhoods) might lead to increased drug use among youth of this age in the future. Youth who have used or sold heroin or cocaine (perhaps because of poor prospects for legal employment), who have close social relationships with drug injectors, or who have undergone traumatic experiences such as sex abuse may be at particularly high risk of becoming drug injectors or crack smokers.10–14 Although marijuana users may sometimes be at enhanced risk of becoming “hard drug” users and drug injectors, this may be less likely to be true in neighborhoods where youth create a cultural separation between widely accepted marijuana use and highly stigmatized use of heroin and cocaine and drug injection. Such a separation has been a conscious aim of Dutch drug policy.15
The rates of heroin and cocaine use, and of drug injection, may reflect a community response to the highly visible negative consequences of drug injection, crack smoking, and HIV/acquired immunodeficiency syndrome in this community.16 The levels of self‐reported heroin and cocaine use among these Bushwick youth are comparable to national data for youth of the same ages from the Monitoring the Future study and the National Household Survey on Drug Abuse.17,18 These national data, of course, primarily reflect the behaviors of youth in environments devoid of the high levels of poverty, drug dealing, and street drug use found in Bushwick. Further studies of “resilient” youth in high‐risk neighborhoods are clearly needed. In addition, the extent of underreporting of heroin use (2 of 5 with any evidence of heroin use denied ever using it), cocaine use (2 of 12 with any evidence of cocaine use denied ever using it), and perhaps of drug injecting (only 1 self‐report, but 3 additional youth were hepatitis C virus positive) suggests the need for caution in interpreting self‐reported data on these specific behaviors.
The subjects also appear to be avoiding sexual relationships with known drug injectors and crack smokers who might be sources of HIV transmission. Nevertheless, most subjects are sexually active, almost half had multiple partners in the prior year, a majority of women have been pregnant, and less than a fifth report consistent condom use.
There is a disparity between the relatively low observed rates of heroin and cocaine use, of drug injection, and of hepatitis B virus and HIV infection‐which may be important future health problems for these youth‐and the high rates of chlamydial and HSV‐2 infection, which are clearly already substantial health problems. The HSV‐2 rates are higher than those among youth in a high‐risk San Francisco neighborhood with fewer drug injectors (Robert Fullilove, personal communication, August 9, 1995), where 16% of 20‐ to 24‐year‐olds and 24% of 25‐ to 29‐year‐olds were infected.19
This study shows the value of studying population‐representative samples in high‐risk communities. It also suggests that efforts‐perhaps including sex education, sexually transmitted disease (STD) screening and out‐reach strategies‐are needed to prevent unwanted pregnancies, STDs, STD sequelae (including potential increased susceptibility to HIV infection), and STD transmission to partners.
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13. Paone D, Chavkin W, Willets I, Friedmann P, Des Jarlais DC. The impact of sexual abuse: Implications for drug treatment. Journal of Women's Health 1992; 1:149-153.
14. van Ameijden EJC, van den Hoek JAR, Hartgers C, Coutinho RA. Risk factors for the transition from non-injecting to injecting drug use and accompanying AIDS risk behavior in a cohort of drug users. Am J Epidemiol 1994; 139:1153-1163.
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