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.1–16
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)1,2,5,6,9,17–19 and to be subordinated and isolated within drug users’ 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.22–24 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%–54%). 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.22–24
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 ▶). 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 1—
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 1997–March 1999
| Odds Ratio (or Linear Regression Coefficient β) | 95% Confidence Interval | |
| Mean age | β = −0.642 | −1.208, −0.076 |
| Race/ethnicity | ||
| White | 1.245 | 0.893, 1.736 |
| Black | 0.835 | 0.533, 1.309 |
| Hispanic | 0.612 | 0.369, 1.013 |
| Other | 1.379 | 0.772, 2.461 |
| Housing status | ||
| Homeless, past 6 mos | 1.772 | 1.275, 2.462 |
| Lived on the street (park, bus or train station, under highway overpass, alleys, rooftops), past 6 mos | 0.954 | 0.582, 1.564 |
| Income | ||
| Most money from state or federal benefits, welfare, or public assistance, past 6 mos | 0.380 | 0.207, 0.697 |
| Most 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 | β = −1.001 | −1.587, −0.415 |
| Institutionalization experience | ||
| Ever in mental health ward or facility | 1.855 | 1.339, 2.571 |
| Ever spent time in correctional facility, jail, juvenile detention center or juvenile hall, or prison | 1.630 | 1.157, 2.295 |
| In drug detoxification, drug treatment, or Narcotics Anonymous, past 6 mos | 0.934 | 0.684, 1.276 |
| Infections | ||
| Hepatitis B core antibody positive | 1.770 | 1.222, 2.563 |
| Hepatitis C positive | 0.921 | 0.660, 1.285 |
| Chlamydia | 0.753 | 0.365, 1.553 |
| Gonorrhea | 0.134 | 0.017, 1.037 |
| HIV seropositive | 1.828 | 0.987, 3.384 |
| Site HIV prevalence, % | ||
| ≤ 10 | 1.129 | 0.433, 2.945 |
| >10 | 2.636 | 1.175, 5.915 |
| Risk and transmission behaviors, past 6 mos | ||
| Injected at least daily | 1.152 | 0.846, 1.570 |
| Engaged in receptive syringe sharing | 1.692 | 1.241, 2.306 |
| Shared rinse water | 1.540 | 1.135, 2.090 |
| Backloaded | 1.171 | 0.843, 1.628 |
| Received money or drugs for sex | 2.201 | 1.557, 3.112 |
| Shared cooker | 1.300 | 0.942, 1.792 |
| Shared cotton | 1.305 | 0.963, 1.768 |
| Put 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 | ||
| Ever injected with MSM IDU | 2.792 | 1.900, 4.104 |
| Ever had unprotected sex with MSM IDU | 3.423 | 2.079, 5.636 |
| Ever injected with WSW IDUs | 5.133 | 3.629, 7.260 |
| Ever injected with an IDU who was at least 5 years older | 1.599 | 1.149, 2.224 |
| Ever injected with anyone who had hepatitis | 1.764 | 1.154, 2.699 |
| Ever had sex with an IDU | 1.734 | 1.163, 2.587 |
| Ever had sex with someone you knew or thought had HIV | 2.504 | 1.547, 4.053 |
| Ever injected with anyone who had HIV | 1.422 | 0.933, 2.169 |
| Ever had sex with someone you knew or thought had AIDS | 1.831 | 0.857, 3.912 |
| Ever had sex with someone you knew or thought had hepatitis B or C | 1.165 | 0.737, 1.840 |
| Ever had sex with someone you knew or thought had gonorrhea | 2.127 | 0.917, 4.936 |
| Ever had sex with someone you knew or thought had chlamydia | 1.584 | 0.853, 2.941 |
| Mean no. of male sex partners | β = 10.596 | 1.519, 19.673 |
Note. MSM = men who have sex with men. Backloading refers to injecting drugs using drugs from another user’s 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 “had hepatitis.” 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 ▶). 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 2—
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 1997–March 1999
| Dependent Variable | Adjusted Odds Ratio | 95% Confidence Interval |
| Personal characteristics | ||
| Most money from selling sex, past 6 mos | 1.093 | 0.665, 1.797 |
| Ever 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 |
| Ever incarcerated | 1.525 | 1.074, 2.164 |
| Ever in mental health ward or facility | 1.747 | 1.253, 2.435 |
| Homeless, past 6 mos | 1.755 | 1.257, 2.451 |
| Risk behaviors | ||
| Engaged in receptive syringe sharing | 1.690 | 1.234, 2.316 |
| Shared rinse water | 1.549 | 1.360, 2.112 |
| Shared cotton | 1.309 | 0.962, 1.783 |
| Mean no. of male sexual partners | β = 3.505 | −5.145, 12.154 |
| Risk networks | ||
| Ever injected with anyone who had hepatitis | 1.680 | 1.093, 2.580 |
| Ever injected with another IDU who was at least 5 years older | 1.423 | 1.016, 1.994 |
| Ever injected with other WSW | 4.923 | 3.466, 6.992 |
| Ever had sex with an IDU | 1.726 | 1.152, 2.586 |
| Ever injected with MSM IDU | 2.824 | 1.910, 4.177 |
| Ever had unprotected sex with MSM IDU | 3.470 | 2.088, 5.767 |
| Ever had sex with someone you knew or thought had HIV | 2.207 | 1.353, 3.601 |
| Ever injected with someone who had HIV | 1.298 | 0.844, 1.996 |
| Ever had sex with someone you knew or thought had AIDS | 1.479 | 0.679, 3.218 |
| Ever had sex with someone you knew or thought had chlamydia | 1.713 | 0.727, 4.037 |
| Infections overall | ||
| Hepatitis B core antibody positive | 1.548 | 1.059, 2.263 |
| HIV seropositivea | 1.607 | 0.857, 3.013 |
| In the 2 sites with HIV prevalence >10% | ||
| Ever injected drugs with a person who was HIV positive | 3.951 | 1.463, 10.672 |
| HIV seropositive | 2.548 | 1.120, 5.797 |
| In the 4 sites with HIV prevalence <10% | ||
| Ever injected drugs with a person who was HIV positive | 1.018 | 0.632, 1.640 |
| HIV 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 anti–hepatitis B virus–positive. 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 populations2,25–30 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 (“HIV Risk Among Women IDUs Who Have Sex With Women”) 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
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