Women injection drug users who have sex with women (WSW IDUs) constitute 20% to 30% of American women IDUs.1 Compared with other women IDUs, WSW IDUs have higher HIV prevalence and incidence rates and a greater likelihood of engaging in high-risk injection and sexual practices with men.1β16
Previous reports suggested that WSW IDUs may be particularly likely to engage in drug injection and sex with men who have sex with men (MSM)1,2,5,6,9,17β19 and to be subordinated and isolated within drug usersβ social milieus and more generally.1,20,21 Historical and generational factors may have changed some relationships as a consequence of the HIV epidemic itself, however. Ethnographic data from New York City and Boston, Mass, suggest that many older MSM IDUs and WSW IDUs who injected drugs together may have died earlier in the epidemic, which might reduce the extent to which WSW IDUs currently engage in drug injection and sex with MSM. To further examine HIV risk among WSW IDUs, we compared social situations, injection and sexual networks, and behaviors of young WSW IDUs with those of other young women IDUs.
METHODS
A post hoc analysis was conducted of data collected from July 1997 to March 1999 from street-recruited women IDUs (predominantly heroin and cocaine injectors) aged 18 to 30 years near 6 research sites in 5 US cities.22β24 Trained research staff conducted face-to-face interviews and collected blood and urine samples after obtaining informed consent.
Women who reported having had sex with a woman during the preceding 6 months or who self-identified as lesbian or bisexual were classified as WSW (n = 274). Classifications as WSW or non-WSW could be made for 803 participants. Proportions of WSW among women IDUs varied by site (20%β54%). Because sites also varied on many other variables, statistical analyses controlled for site.
Because predictors of HIV seroconversion among IDUs (and, therefore, prevalence among new injectors) differ by local prevalence,5 we analyzed HIV serostatus separately within 4 sites with HIV prevalence lower than 6% in the total sample and within 2 sites with HIV prevalence greater than 10%.
The questionnaire covered sociodemographic characteristics and sexual and drug-using behaviors and partnerships, usually for the 6 months before the interview. Sera were tested for antibody against HIV-1, hepatitis B virus, and hepatitis C virus; urine was tested for chlamydia and gonorrhea with ligase chain reaction.22β24
RESULTS
Of the 803 women IDUs, 45% reported having been homeless in the prior 6 months, and 28% reported having received money for sex during this period. Controlling for site, WSW IDUs were slightly younger than non-WSW IDUs (Table 1 βΆ). WSW IDUs were more likely to have been recently homeless, to have ever been institutionalized in a mental health facility, and to have ever been incarcerated. They were less likely to receive most of their income from welfare, a relatively stable income source for young IDUs, and more likely to receive most of their income from selling sex.
TABLE 1β
Association Between Being Women Injection Drug Users Who Have Sex With Women (WSW IDUs) and Selected Variables, Controlling for Recruitment Site: 6 Sites in 5 US Cities, July 1997βMarch 1999
| Odds Ratio (or Linear Regression Coefficient Ξ²) | 95% Confidence Interval | |
| Mean age | Ξ² = β0.642 | β1.208, β0.076 |
| Race/ethnicity | ||
| ββββWhite | 1.245 | 0.893, 1.736 |
| ββββBlack | 0.835 | 0.533, 1.309 |
| ββββHispanic | 0.612 | 0.369, 1.013 |
| ββββOther | 1.379 | 0.772, 2.461 |
| Housing status | ||
| ββββHomeless, past 6 mos | 1.772 | 1.275, 2.462 |
| ββββLived on the street (park, bus or train station, under highway overpass, alleys, rooftops), past 6 mos | 0.954 | 0.582, 1.564 |
| Income | ||
| ββββMost money from state or federal benefits, welfare, or public assistance, past 6 mos | 0.380 | 0.207, 0.697 |
| ββββMost money from selling sex, past 6 mos | 1.888 | 1.270, 2.805 |
| Completed high school or received general equivalency diploma | 1.175 | 0.864, 1.597 |
| Mean age at first injection | Ξ² = β1.001 | β1.587, β0.415 |
| Institutionalization experience | ||
| ββββEver in mental health ward or facility | 1.855 | 1.339, 2.571 |
| ββββEver spent time in correctional facility, jail, juvenile detention center or juvenile hall, or prison | 1.630 | 1.157, 2.295 |
| ββββIn drug detoxification, drug treatment, or Narcotics Anonymous, past 6 mos | 0.934 | 0.684, 1.276 |
| Infections | ||
| ββββHepatitis B core antibody positive | 1.770 | 1.222, 2.563 |
| ββββHepatitis C positive | 0.921 | 0.660, 1.285 |
| ββββChlamydia | 0.753 | 0.365, 1.553 |
| ββββGonorrhea | 0.134 | 0.017, 1.037 |
| ββββHIV seropositive | 1.828 | 0.987, 3.384 |
| Site HIV prevalence, % | ||
| βββββ€ 10 | 1.129 | 0.433, 2.945 |
| ββββ>10 | 2.636 | 1.175, 5.915 |
| Risk and transmission behaviors, past 6 mos | ||
| ββββInjected at least daily | 1.152 | 0.846, 1.570 |
| ββββEngaged in receptive syringe sharing | 1.692 | 1.241, 2.306 |
| ββββShared rinse water | 1.540 | 1.135, 2.090 |
| ββββBackloaded | 1.171 | 0.843, 1.628 |
| ββββReceived money or drugs for sex | 2.201 | 1.557, 3.112 |
| ββββShared cooker | 1.300 | 0.942, 1.792 |
| ββββShared cotton | 1.305 | 0.963, 1.768 |
| ββββPut drugs together at least half the time | 1.205 | 0.868, 1.674 |
| Obtained most syringes from a syringe exchange, past 6 mos | 1.160 | 0.824, 1.633 |
| Networks | ||
| ββββEver injected with MSM IDU | 2.792 | 1.900, 4.104 |
| ββββEver had unprotected sex with MSM IDU | 3.423 | 2.079, 5.636 |
| ββββEver injected with WSW IDUs | 5.133 | 3.629, 7.260 |
| ββββEver injected with an IDU who was at least 5 years older | 1.599 | 1.149, 2.224 |
| ββββEver injected with anyone who had hepatitis | 1.764 | 1.154, 2.699 |
| ββββEver had sex with an IDU | 1.734 | 1.163, 2.587 |
| ββββEver had sex with someone you knew or thought had HIV | 2.504 | 1.547, 4.053 |
| ββββEver injected with anyone who had HIV | 1.422 | 0.933, 2.169 |
| ββββEver had sex with someone you knew or thought had AIDS | 1.831 | 0.857, 3.912 |
| ββββEver had sex with someone you knew or thought had hepatitis B or C | 1.165 | 0.737, 1.840 |
| ββββEver had sex with someone you knew or thought had gonorrhea | 2.127 | 0.917, 4.936 |
| ββββEver had sex with someone you knew or thought had chlamydia | 1.584 | 0.853, 2.941 |
| Mean no. of male sex partners | Ξ² = 10.596 | 1.519, 19.673 |
Note. MSM = men who have sex with men. Backloading refers to injecting drugs using drugs from another userβs syringe.
WSW IDUs were more likely to have positive test results for hepatitis B virus (but not for hepatitis C virus, chlamydia, or gonorrhea) and were more likely to be infected with HIV in high-prevalence, but not low-prevalence, sites. WSW IDUs were more likely to engage in high-risk behaviors (receptive syringe sharing, sharing rinse water, and sex trading) and reported having more male sexual partners. WSW IDUs were more likely to report having unprotected sex with MSM; having sex with an IDU or someone they knew or thought was infected with HIV; and injecting drugs with MSM, WSW IDUs, someone at least 5 years older, and someone who βhad hepatitis.β They were more likely to have ever injected drugs with MSM in low-HIV-prevalence, but not high-HIV-prevalence, sites.
Significant associations were analyzed further, controlling for both site and receiving money or drugs for sex (Table 2 βΆ). WSW IDUs remained significantly more likely to have been institutionalized, to have been homeless, to have engaged in receptive syringe sharing, to have shared rinse water, and to have had high-risk partners (such as MSM IDUs, older IDUs, WSW IDUs, and IDUs who had HIV or hepatitis) in their injection and sexual networks. In high-HIV-prevalence sites, WSW IDUs were more likely to have injected drugs with a person who is HIV positive (adjusted odds ratio = 3.95) and to be HIV seropositive (adjusted odds ratio = 2.55).
TABLE 2β
Adjusted Odds Ratios and Confidence Intervals for Association Between Being Women Injection Drug Users Who Have Sex With Women (WSW IDUs) and Selected Dependent Variables, Controlling for Site, and Having Traded Sex for Money or Drugs in the Past 6 Months: 6 Sites in 5 US Cities, July 1997βMarch 1999
| Dependent Variable | Adjusted Odds Ratio | 95% Confidence Interval |
| Personal characteristics | ||
| ββββMost money from selling sex, past 6 mos | 1.093 | 0.665, 1.797 |
| ββββEver spent time in a correctional facility, jail, juvenile detention center or juvenile hall, prison, mental health ward of hospital, mental health facility, or other institution | 1.686 | 1.151, 2.470 |
| ββββEver incarcerated | 1.525 | 1.074, 2.164 |
| ββββEver in mental health ward or facility | 1.747 | 1.253, 2.435 |
| ββββHomeless, past 6 mos | 1.755 | 1.257, 2.451 |
| Risk behaviors | ||
| ββββEngaged in receptive syringe sharing | 1.690 | 1.234, 2.316 |
| ββββShared rinse water | 1.549 | 1.360, 2.112 |
| ββββShared cotton | 1.309 | 0.962, 1.783 |
| ββββMean no. of male sexual partners | Ξ² = 3.505 | β5.145, 12.154 |
| Risk networks | ||
| ββββEver injected with anyone who had hepatitis | 1.680 | 1.093, 2.580 |
| ββββEver injected with another IDU who was at least 5 years older | 1.423 | 1.016, 1.994 |
| ββββEver injected with other WSW | 4.923 | 3.466, 6.992 |
| ββββEver had sex with an IDU | 1.726 | 1.152, 2.586 |
| ββββEver injected with MSM IDU | 2.824 | 1.910, 4.177 |
| ββββEver had unprotected sex with MSM IDU | 3.470 | 2.088, 5.767 |
| ββββEver had sex with someone you knew or thought had HIV | 2.207 | 1.353, 3.601 |
| ββββEver injected with someone who had HIV | 1.298 | 0.844, 1.996 |
| ββββEver had sex with someone you knew or thought had AIDS | 1.479 | 0.679, 3.218 |
| ββββEver had sex with someone you knew or thought had chlamydia | 1.713 | 0.727, 4.037 |
| Infections overall | ||
| ββββHepatitis B core antibody positive | 1.548 | 1.059, 2.263 |
| ββββHIV seropositivea | 1.607 | 0.857, 3.013 |
| In the 2 sites with HIV prevalence >10% | ||
| ββββEver injected drugs with a person who was HIV positive | 3.951 | 1.463, 10.672 |
| ββββHIV seropositive | 2.548 | 1.120, 5.797 |
| In the 4 sites with HIV prevalence <10% | ||
| ββββEver injected drugs with a person who was HIV positive | 1.018 | 0.632, 1.640 |
| ββββHIV seropositivea | 0.865 | 0.323, 2.318 |
Note. MSM = men who have sex with men.
aData for New Orleans, La, were omitted from the analyses of HIV prevalence because the lack of any infected subjects from that location led to quasi-complete separation in the estimates.
DISCUSSION
Compared with other young women IDUs, WSW IDUs were more likely to have been institutionalized or homeless, to have engaged in riskier behaviors, to have had high-risk sexual and injection networks (as described in the previous paragraph), and to have been antiβhepatitis B virusβpositive. In high-HIV-prevalence sites, they were more likely to have been infected with HIV. These differences cannot be accounted for by their greater involvement in sex work.
Interpretation must take account of study limitations. Some data, including questions used to define WSW IDUs, were collected for other purposes. Analyses of interactions by site, sometimes limited by small cell numbers, indicate local variation in some relationships. Underreporting of same-sex sexual behavior or other variables may affect statistical associations. Reporting bias may have occurred if WSW IDUs were more likely than the non-WSW IDUs to know that their male injection or sexual partners have had sex with men.
Studies of drug users and other populations2,25β30 should consider sexual identity and sex between women, which may help explain variations in homelessness, institutionalization, behavior, networks, and infection rates. Research and interventions targeting IDUs should incorporate issues of sexual identity and same-sex sexual behaviors among women and find ways to deal with related social and economic issues.
Acknowledgments
The Collaborative Injection Drug Users Study (CIDUS II) was funded by a collaborative agreement with Centers for Disease Control and Prevention (CDC). Other support included National Institutes of Health Grant R01 DA10870 (βHIV Risk Among Women IDUs Who Have Sex With Womenβ) and a National Institute on Drug Abuse minority supplement to an R01 (R01 DA11880-03S1) for D. C. Ompad.
The authors would like to acknowledge Ian Williams, Mar Than, and Michael Purdy of the CDC Hepatitis Branch for providing hepatitis B and hepatitis C virus testing and interpretation of results; Carol Farshy of CDC, Division of AIDS, STD, TB Laboratory Research, for providing gonorrhea and chlamydia testing; and Andrea Swartzendruber and Roberto Valverde for ensuring the quality of the CIDUS II data and providing thoughtful review of this manuscript.
Human Participant Protection
Potential participants in the study received information about the study and provided informed consent in the local study office or mobile van. They were also given a small honorarium for their time and travel after completion of an interview. Face-to-face interviews were then conducted by trained research staff; thereafter, with informed consent, blood was drawn for testing. Institutional review boards for the Centers for Disease Control and Prevention and for each local site approved the study and its procedures.
Contributors
S. R. Friedman conceived of the brief and wrote it. D. C. Ompad, C. Maslow, and T. Perlis worked on analyses and interpretation. R. Young, P. Case, and A. Hollibaugh, who were part of an ethnographic study of women injection drug users who have sex with women, contributed to the initial conception for the brief and also to the analyses. S. M. Hudson, T. Diaz, E. Morse, S. Bailey, and D. C. Des Jarlais were site representatives for this multisite project and also provided constant feedback as we wrote the brief. R. S. Garfein was the Centers for Disease Control project officer for the multisite project; he was deeply involved in writing the questionnaire, in other aspects of study design, and in the process of writing the brief.
Peer Reviewed
References
- 1.Young RM, Friedman SR, Case PL, Asencio MW, Clatts M. Women injection drug users who have sex with women exhibit increased infection and risk behaviors. J Drug Issues. 2000;30:499β524. [Google Scholar]
- 2.Solarz A, ed. Lesbian Health: Current Assessment and Directions for the Future. Washington, DC: National Academy Press; 1999. [PubMed]
- 3.Bevier PJ, Chiasson MA, Heffernan RT, Castro KG. Women at a sexually transmitted disease clinic who reported same-sex contact: their HIV seroprevalence and risk behaviors. Am J Public Health. 1995;85:1366β1371. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Ehrhardt AA, Noestlinger C, Meyer-Bahlburg HFL, Exner TM. Sexual risk behavior among women with injected drug use histories. J Psychol Hum Sexuality. 1995;7:99β119. [Google Scholar]
- 5.Friedman SR, Jose B, Deren S, Des Jarlais DC, Neaigus A. Risk factors for human immunodeficiency virus seroconversion among out-of-treatment drug injectors in high and low seroprevalence cities. The National AIDS Research Consortium. Am J Epidemiol. 1995;142:864β874. [DOI] [PubMed] [Google Scholar]
- 6.Friedman SR, Curtis R, Neaigus A, Jose B, Des Jarlais DC. Social Networks, Drug Injectorsβ Lives, and HIV/AIDS. New York, NY: Kluwer Academic/Plenum Publishers; 1999.
- 7.Harris NV, Thiede H, McGough JP, Gordon D. Risk factors for HIV infection among injection drug users: results of blinded surveys in drug treatment centers, King County, Washington 1988β1991. J Acquir Immune Defic Syndr. 1993;6:1275β1282. [PubMed] [Google Scholar]
- 8.Jose B, Friedman SR, Neaigus A, et al. Syringe-mediated drug-sharing (backloading): a new risk factor for HIV among injecting drug users. AIDS. 1993;7:1653β1660. [DOI] [PubMed] [Google Scholar]
- 9.Lemp GF, Jones M, Kellogg TA, et al. HIV seroprevalence and risk behaviors among lesbians and bisexual women in San Francisco and Berkeley, California. Am J Public Health. 1995;85:1549β1552. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Reardon J, Wilson MJ, Lemp GF, et al. HIV-1 infection among female injection drug users (IDU) in the San Francisco Bay Area, California 1989β1991. In: Program and abstracts of the VIII International Conference on AIDS; 19β24July1992; Amsterdam, the Netherlands. Abstract ThC1553.
- 11.Ross MW, Wodak A, Gold J, Miller ME. Differences across sexual orientation on HIV risk behaviours in injecting drug users. AIDS Care. 1992;4:139β148. [DOI] [PubMed] [Google Scholar]
- 12.Williams ML, Elwood WN, Weatherby NL, et al. An assessment of the risks of syphilis and HIV infection among a sample of not-in-treatment drug users in Houston, Texas. AIDS Care. 1996;8:671β682. [DOI] [PubMed] [Google Scholar]
- 13.Deren S, Estrada AL, Stark M, Goldstein M. Sexual orientation and HIV risk behaviors in a national sample of injection drug users and crack smokers. Drugs Soc. 1996;9:97β108. [Google Scholar]
- 14.Kral AH, Lorvick J, Bluthenthal RN, Watters JK. HIV risk profile of drug-using women who have sex with women in 19 United States cities. J Acquir Immune Defic Syndr Hum Retrovirol. 1997;16:211β217. [DOI] [PubMed] [Google Scholar]
- 15.Weissman G. Drug use patterns among gay and bisexual men and lesbians in a national study. Paper presented at: National Gay and Lesbian Health Forum; 19July1990.
- 16.Young RM, Weissman G, Cohen JB. Assessing risk in the absence of information: HIV risk among women injection-drug users who have sex with women. AIDS Public Policy J. 1992;7:175β183. [Google Scholar]
- 17.Case P, Downing M, Ferguson B, Lorvick J, Sanchez L. The social context of AIDS risk behavior among intravenous drug using lesbians in San Francisco. In: Program and abstracts of the IV International Conference on AIDS; 12β16June1998; Stockholm, Sweden. Abstract ThC1553.
- 18.Young RM. Methodology at the margins: researching lesbian health. Paper presented at: 121st Annual Meeting of the American Public Health Association; 24β28October1993; San Francisco, Calif. Abstract 1170.
- 19.Hollibaugh RM, Vazquez C. The myth of invulnerability: lesbians and HIV disease. FOCUS: A Guide to AIDS Research and Counseling. 1994;8:1β4. [Google Scholar]
- 20.Cochran SD, Mays VM. Depressive distress among homosexually active African American men and women. Am J Psychiatry. 1994;151:524β529. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Zierler S, Krieger N. Reframing womenβs risk: social inequalities and HIV infection. Annu Rev Public Health. 1997;18:401β436. [DOI] [PubMed] [Google Scholar]
- 22.Latka M, Ahern J, Garfein RS, et al. Prevalence, incidence, and correlates of chlamydia and gonorrhea among young adult injection drug users. J Subst Abuse. 2001;13(1β2):73β88. [DOI] [PubMed] [Google Scholar]
- 23.Kapadia F, Vlahov D, Des Jarlais DC, et al. Does bleach disinfection of syringes protect against hepatitis C infection among young adult injection drug users? Epidemiology. 2002;13:738β741. [DOI] [PubMed] [Google Scholar]
- 24.Diaz T, Vlahov D, Greenberg B, Cuevas Y, Garfein R. Sexual orientation and HIV infection prevalence among young Latino injection drug users in Harlem. J Womens Health Gender-Based Med. 2001;10:371β380. [DOI] [PubMed] [Google Scholar]
- 25.Aaron DJ, Markovic N, Danielson ME, Honnold JA, Janosky JE, Schmidt NJ. Behavioral risk factors for disease and preventive health practices among lesbians. Am J Public Health. 2001;91:972β975. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Cochran BN, Stewart AJ, Ginzler JA, Cauce AM. Challenges faced by homeless sexual minorities. Am J Public Health. 2002;92:773β777. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Gilman SE, Cochran SD, Mays VM, Hughes M, Ostrow D, Kessler RC. Risk of psychiatric disorders among individuals reporting same-sex sexual partners in the National Comorbidity Survey. Am J Public Health. 2001;91:933β939. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Gruskin EP, Hart S, Gordon N, Ackerson L. Patterns of cigarette smoking and alcohol use among lesbians and bisexual women enrolled in a large health maintenance organization. Am J Public Health. 2001;91:976β979. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Mays VM, Yancey AK, Cochran SD. Heterogeneity of health disparities among African American, Hispanic, and Asian American women: unrecognized influences of sexual orientation. Am J Public Health. 2002;92:632β639. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Meyer IH. Why lesbian, gay, bisexual, and transgender public health? Am J Public Health. 2001;91:856β859. [DOI] [PMC free article] [PubMed] [Google Scholar]