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number of events for both Chlamydia and genital warts, and the fifth highest mean number of events for genital herpes (unpublished data).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.
1. Chitwood DD, Griffin DK, Comerford M, Page JB, Lai S, McCoy CB. Risk factors for HIV-1 seroconversion among injection drug users: a case-control study. Am J Pub Health 1995; 85:1538-1542.
2. Lamothe F, Bruneau J, Coates R, et al. Seroprevalence of and risk factors for HIV-1 infection in injection drug users in Montreal and Toronto: a collaborative study. Can Med Assoc J 1993; 149:945-951.
3. Marmor M, Des Jarlais DC, Cohen H, et al. Risk factors for infection with human immunodeficiency virus among intravenous drug abusers in New York City. AIDS 1987; 1:39-44.
4. Baker A, Kochan N, Dixon J, Wodak A, Heather N. Drug use and HIV risk-taking behavior among injecting drug users not currently in treatment in Sydney, Australia. Drug Alcohol Depend 1994; 34:155-160.
5. Feucht TE, Stephens RC, Roman SW. The sexual behavior of intravenous drug users: Assessing the risk of sexual transmission of HIV. J Drug Issues 1990; 20:195-213.
6. Kim MY, Marmor M, Dubin N, Wolfe H. HIV risk-related sexual behaviors among heterosexuals in New York City: associations with race, sex, and intravenous drug use. AIDS 1993; 7:409-414.
7. Lewis DK, Watters JK. Sexual behavior and sexual identity in male injection drug users. J Acquir Immune Defic Syndr Hum Retrovirol 1994; 7:190-198.
8. Wells EA, Calsyn DA, Saxon AJ, Greenberg DM. Using drugs to facilitate sexual behavior is associated with sexual variety among injection drug users. J Nerv Ment Dis 1993; 181:626-631.
9. van den Hoek JAR, Van Haastrecht HJA, Coutinho RA. Little change in sexual behavior in injecting drug users in Amsterdam. J Acquir Immune Defic Syndr Hum Retrovirol 1992; 5:518-522.
10. Fitterling JM, Matens PB, Scotti JR, Allen JS. AIDS risk behaviors and knowledge among heterosexual alcoholics and non-injecting drug users. Addiction 1993; 88:1257-1265.
11. McKeganey NP, Barnard MA, Watson H. HIV related risk behaviour among a non-clinic sample of injecting drug users. Br J Addiction 1989; 84:1481-1490.
12. McKusker J, Stoddard AM, Zapka JG, Lewis BF. Behavioral outcomes of AIDS educational interventions for drug users in short-term treatment. Am J Pub Health 1993; 83:1463-1466.
13. Watters JK, Downing M, Case P, Lorvick J, Cheng Y-T, Fergusson B. AIDS prevention for intravenous drug users in the community: Street-based education and risk behavior. Am J Commun Psychol 1990; 18:587-596.
14. Donoghoe MC, Stimson GV, Dolan K, Alldritt L. Changes in HIV risk behaviour in clients of syringe-exchange schemes in England and Scotland. AIDS 1989; 3:267-272.
15. Kall K, Olin RG. HIV status and changes in risk behavior among intravenous drug users in Stockholm 1987-1988. AIDS 1990; 4:153-157.
16. Friedman SR, Nealgus A, Des Jarlais DC, et al. Social interventions against AIDS among injecting drug users. Br J Addiction 1992; 87:393-404.
17. Fisher DG, Anglin MD, Weisman CP, Pulliam L. Replication problems of substance abuser MMPI cluster types. Multivar Behav Res 1989; 24:335-352.
18. Swadi H. Psychiatric symptoms in drug abusing adolescents. Drug Alcohol Depend 1992; 31:77-83.
19. Fals-Stewart W. Personality characteristics of substance abusers: An MCMI cluster typology of recreational drug users treated in a therapeutic community and its relationship to length of stay and outcome. J Pers Assess 1992; 59:515-527.
20. Isenhart CE. Motivational subtypes in an inpatient sample of substance abusers. Addictive Behav 1994; 19:463-475.
21. Stall R, McKusick L, Wiley J, Coates TJ, Ostrow DG. Alcohol and drug use during sexual activity and compliance with safe sex guidelines for AIDS: The AIDS Behavioral Research Project. Health Educ Q 1986; 13:359-371.
22. Hingson RW, Strunin L, Berlin BM, Heeren T. Beliefs about AIDS, use of alcohol and drugs, and unprotected sex among Massachusetts adolescents. Am J Public Health 1990; 80:295-299.
23. Leigh BC, Stall R. Substance use and risky sexual behavior for exposure to HIV: Issues in methodology, interpretation, and prevention. Am Psychol 1993; 48:1035-1045.
24. Crowe LC, George WH. Alcohol and human sexuality: Review and integration. Psychol Bull 1989; 105:541-551.
25. Steele CM, Southwick L. Alcohol and social behavior I: the psychology of drunken excess. J Pers Soc Psychol 1985; 48:18-34.
26. Temple MT, Leigh BC, Schafer J. Unsafe sexual behavior and alcohol use at the event level: Results of a national survey. J Acquir Immune Defic Syndr Hum Retrovirol 1993; 6:393-401.
27. Calsyn DA, Saxon AJ, Wells EA, Greenberg DM. Longitudinal sexual behavior changes in injecting drug users. AIDS 1992; 6:1207-1211.
28. Latkin C, Mandell W, Oziemkowska M, Vlahov D, Celentano D. The relationships between sexual behavior, alcohol use, and personal network characteristics among injecting drug users in Baltimore, Maryland. Sex Transm Dis 1994; 21:161-167.
29. Turner S, Paschane D, Johnson M, Fenaughty A, Fisher G. Alcohol consumption by Alaskan drug users not currently in treatment. Poster presented at the 10th International Circumpolar Conference on Health, Anchorage, AK. 1996.
30. Falck RS, Wang J, Carlson RG, Siegal HA. Factors influencing condom use among heterosexual users of injection drugs and crack cocaine. Sex Trasm Dis 1997; 24:204-210.
31. Watters JK, Biernacki P. Targeted sampling: Options for the study of hidden populations. Soc Probl 1989; 36:416-430.
32. National Institute on Drug Abuse. Risk behavior assessment. Rockville, MD: National Institute on Drug Abuse (Community Research Branch), 1991.
33. Fisher DG, Needle R, Weatherby N, et al. Reliability of drug user self-report. IXth International Conference on AIDS. Berlin, Germany, 1993. Abstract (PO-C35-3355).
34. Needle R, Fisher DG, Weatherby N, et al. The reliability of self-reported HIV risk behaviors of drug users. Psychol Addictive Behav 1995; 9:242-250.
35. Dowling-Guyer S, Johnson ME, Fisher DG, et al. Reliability of drug users' self-reported HIV risk behaviors and validity of self-reported recent drug use. Assessment 1994; 1:383-392.
36. Weatherby NL, Needle R, Cesari H, et al. Validity of self-reported drug use among injection drug users and crack cocaine users recruited through street outreach. Eval Prog Plan 1994; 17:347-355.
37. Zuckerman M. Sensation seeking: beyond the optimal level of arousal. Hillsdale, NJ: Lawrence Erlbaum Associates, 1979.
38. Schafer J, Blanchard L, Fals-Stewart W. Drug use and risky sexual behavior. Psychol Addictive Behav 1994; 8:3-7.
39. Zuckerman M, Kolin EA, Price L, Zoob I. Development of a sensation-seeking scale. J Consult Clin Psychol 1964; 28:477-482.
40. Zuckerman M. Dimensions of sensation seeking. J Consult Clin Psychol 1971; 36:45-52.
41. Aldenderfer M, Blashfield RK. Cluster Analysis. Sage University Paper series on Quantitative Applications in the Social Sciences, 07-044. London: Sage Publications, 1984.
42. Wishart D. Clustan user manual, 4th ed. Edinburgh: Program Library Unit, Edinburgh University, 1987.
43. SAS Institute Inc. SAS/STAT User's guide. Version 6, 4th ed., Vols 1 & 2. Cary, NC: SAS Institute Inc., 1989.
44. Watters JK, Lewis DK. HIV infection, race, and drug-treatment history. AIDS 1990; 4:697-702.
45. Tumer S, Paschane D, Johnson M, Fenaughty A, Fisher G. Alcohol consumption by Alaskan drug users not currently in treatment. Poster presented at the 10th International Circumpolar Conference on Health, Anchorage, AK, 1996.
46. Schilling R, Serrano Y, Faruque S, et al. Predictor variables of trading sex among male drug users in Harlem. International Conference on AIDS. Abstracts 8(2), C352 1992.
47. Leigh BC. Beliefs about the effects of alcohol on self and others. J Studies Alcohol 1987; 48:467-475.
*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.