Among this sample of out‐of‐treatment drug users, a typology based on patterns of alcohol use was found to be associated with high‐risk sexual behavior. Drug users classified as high risk on the basis of their lifetime and current alcohol use patterns were significantly more likely than low‐risk drug users to have had multiple sex partners and inconsistently used condoms, have had at least one IDU sex partner and not consistently used condoms, and have ever had an STD. Female drug users classified as high risk on the basis of the typology were also more likely to have given sex to get drugs or money. The alcohol typology was also significantly related to number of sex partners, the proportion of protected sex acts, and number of lifetime STDs. Furthermore, these associations were maintained even after controlling for the personality traits of sensation seeking and risk proneness.
These findings suggest that a profile based on a relatively small set of alcohol variables can be used to identify drug users likely to be engaging in a range of sexual behaviors that place them at increased risk of HIV and other STD infection. The present study focused on risk behavior and not disease morbidity as an outcome; however, there is some evidence that STD rates among drug users in the Anchorage area are high enough to pose cause for concern. In a comparison of self‐reported history of STDs among 23 sites nationwide, drug users from the Anchorage site reported* the second highest mean number of events for both Chlamydia and genital warts, and the fifth highest mean number of events for genital herpes (unpublished data). The cohort of drug users in Anchorage has an HIV seroprevalence of 2%.
One implication of this study's findings is that alcohol use profiles could be used to target those drug users who are in most need of preventive interventions that focus on sexual risk reduction. For example, drug users enrolled in alcohol treatment programs and out‐of‐treatment drug users who fit the high‐risk alcohol profile may be targeted for HIV risk reduction interventions. Future research should explore the role of such targeting within preventive interventions and assess the extent to which it improves the effectiveness of the intervention.
The limitations of this study need to be noted. The results should not be generalized to non‐drug using populations or to drug users who are currently in treatment. In‐treatment drug users differ from out‐of‐treatment drug users on a number of variables,31 including HIV infection.44 Furthermore, the extent to which the pattern of alcohol use characterizing the high‐risk cluster would generalize to other out‐of‐treatment drug users is unclear. Alcohol use rates in Alaska are extremely high,45 and patterns of alcohol use may vary by region or culture. However, it is not clear that the association between high‐risk alcohol use and risky sexual behavior is dependent on a high mean level of alcohol use. Future research needs to examine the possible moderating effects of level of alcohol use on the association between high‐risk alcohol use and risky sexual behavior.
The results from this study are consistent with previous research showing an association between alcohol use and sexual risk behavior among drug users.27–29,46 Further, the findings lend strength to the argument made by Latkin et al28 that the association between alcohol use and high‐risk sexual behavior was not because of a risk‐prone or sensation‐seeking personality type. There were associations between some of the personality variables and certain sexual risk behaviors (e.g., number of sex partners and impulsivity and risk taking); however, these associations were consistently unable to account for the association between alcohol typology and risk behavior.
There are a number of theoretical frameworks within which the findings of this study may fit. The results are consistent with a causal disinhibitory explanation for the alcohol‐risk behavior relationship. This explanation posits that alcohol consumption leads to cognitive impairment, which in turn leads to disinhibition of certain sexual behaviors.24–25 Although the correlational methods in the current study preclude causal inference regarding the link between alcohol and risk behavior, the observed pattern of data is what one would expect to find if alcohol were playing a role in the disinhibition of sexual activity (e.g., having multiple partners and not using condoms. However, the data are also consistent with a number of other explanations, including the expectancy effects hypothesis,47 which posits that alcohol affects behavior through the expectancies people hold regarding how alcohol should influence behavior. It is likely that no single explanation accounts for the link between risky alcohol use and risky sexual behavior, but rather that multiple mechanisms underlie this effect.21 Regardless of the exact nature of this mechanism or mechanisms, this study adds to the growing body of research indicating that drug users and their sex partners are in need of HIV prevention services that have been developed with both an understanding of the interrelatedness and complexity of the behaviors they seek to change and an acknowledgment of the heterogeneity of the clients they aim to serve. Alcohol use in particular appears to play a significant role in the HIV risk behavior of drug users. A better understanding of this role and its consequences may indicate the need for differential interventions based on alcohol use.
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*Although self‐report data are not optimal indicators of STD prevalence, there is no reason to assume differential validity of this indicator across the 23 sites. Thus, self‐report gives an indication of STD prevalence in a relative sense. Cited Here...