HIV risk, health, and social characteristics of sexual minority female injection drug users in Baltimore

Abstract

Female injection drug users {IDU} who report sex with women are at increased risk for HIV and social instability, but it is important to assess whether these disparities also exist according to sexual minority identity rather than behaviorally defined categories. Within a sample of current IDU in Baltimore, about 17% of female study participants (n=307) identified as gay/lesbian/bisexual. In controlled models, sexual minorities were three times as likely to report sex exchange behavior and four times as likely to report a recent STI. Injection risk did not differ significantly, but sexual minority women reported higher prevalence of socio-economic instability, negative health indicators, and fewer network financial, material, and health support resources. There is a need to identify and address socio-economic marginalization, social support, and health issues among female IDUs who identify as lesbian or bisexual.

Introduction

Despite increasing recognition of health disparities affecting lesbian, gay, bisexual, and transgender (LGBT) individuals, there remains a need for rigorous research that helps to contextualize LGBT health and inform effective strategies ¹. Research indicates that lesbian and bisexual women are at heightened risk for some health problems, but large gaps in the literature remain ¹.

A few studies have shown increased likelihood of injection drug use (IDU} among sexual minority women compared to heterosexual women. Among attendees at a sexual health center in Sydney Australia, women who reported sex with other women (WSW) were eight times as likely to have IDU history and 7.7 times as likely to have hepatitis C compared to non-WSW controls ². A population-based study of women in low-income neighborhoods of Northern California found that women who reported sex with both men and women were much more likely to report ever and current injection of cocaine, heroin, and speed compared to women who reported sex only with men ³.

Prevalence of same sex partnerships among studies of female IDUs ranges from less than 5% to 53%, depending on definition and study method ⁴. Among injection drug users, a variety of studies have found higher prevalence of injection and sexual risk behaviors for HIV transmission ^4,5 and increased HIV infection ⁴ among sexual minority IDUs. These studies have also shown marked social disparities such as homelessness and incarceration in the lives of sexual minority IDUs, which create stress and contribute to HIV vulnerability.

Much of the research on health disparities among sexual minority women has focused on the behavioral categorization of “women who have sex with women (WSW)”, which may not fully represent the behavioral, partnership, and social diversity among sexual minority women, ⁶ and does not necessarily correspond with one's self-constructed social identity and associated shared social experiences ⁷. This both further contributes to social marginalization and limits the ability to effectively understand and address the needs of lesbian and bisexual women ^7,8. Furthermore, there is a noted need to identify salient differences among sexual minority IDUs and particularly to investigate potential socioeconomic differences that may contribute to increased risk in this community ⁴.

The purpose of this study was to examine HIV risk, health and social characteristics of women IDUs who identify as either lesbian or bisexual compared to women IDUs who identify as heterosexual.

Methods

Data were derived from the STEP into Action study, a social network based intervention among IDUs in Baltimore. Data collection methodology has been described elsewhere ⁹. In brief, the STEP study recruited IDUs through targeted outreach and their social network members to participate in a baseline interview from 2004-2006 (n=1024). Eligible participants were 18 or older; self-reported IDU in past six-months; Baltimore City residents; no participation in other HIV or network studies in past year; and willing to introduce a risk network member to the study. Network members were sex or drug partners of primary participants. The current study is limited to female index or network participants in the baseline survey who reported injection opiate or cocaine use in the past six months (n=307).

Trained staff members conducted face-to-face two-hour interviews using ACASI software for HIV risk behaviors. Participants received $35 for baseline completion. Study protocols were approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.

Sexual orientation was assessed by asking participants if they consider themselves to be gay/lesbian, straight, or bisexual. Sexual minority status was classified as those women who identified as either lesbian or bisexual; sample size did not enable further analysis of potential differences between lesbian and bisexual women. Participants were also asked separately if they had a female sex partner in the past 90 days.

Socio-demographic characteristics included race/ethnicity (African-American vs. white), age (continuous), educational attainment (high school graduation vs. less), partner status (current main vs. none), and child raising status (currently raising child under 18 vs. not). Drug use was assessed by examining frequency of heroin, cocaine, crack, and other drugs and injection frequency (daily vs. less). Socio-economic stability variables were income level ($500/month or less), employment status (full- or part-time vs. not), housing (current housing status and current homelessness), incarceration (time in prison and recent arrest), and specific income sources in the past month.

Social resource and network variables were assessed using an adapted social network inventory. Cumulative numbers of individuals within one's network were calculated for each social resource domain. We examined total number of social network members, network member characteristics (e.g., age, gender, race/ethnicity, drug use status), role relationships (e.g., kin, partner, friend, associate), social support (emotional, material, financial, socialize with, and health-related), and relationship qualities (how much each network member is trusted averaged across network members; and how many network members know one another, known as network density).

A range of mental health, injection risk behaviors, and other HIV-related health outcomes were examined in this exploratory study. Mental health is strongly associated with HIV and related risk; variables included here were depressive symptoms assessed with the Center for Epidemiological Studies Depression scale ¹⁰, ever diagnosed with a mental illness, and ever hospitalized for mental illness. Injection behaviors were frequency, injection with a syringe or equipment (cooker, cotton, or water) used previously and injecting in a shooting gallery. Other health outcomes considered were recent diagnosis of a sexually transmitted disease, diagnosis with hepatitis B or C, having ever overdosed, and HIV status based on results of laboratory testing confirmed with Western-Blot.

Chi-square tests were conducted to identify socio-demographic characteristics associated with sexual minority status. Those variables found to be associated at the p<0.10 level were examined further in bivariate and multivariate logistic models, using GEE to account for network clustering by index. Multivariate models were run separately for each socio-economic stability, social resource, and health-related outcome, controlling for key demographic variables that could influence the relationship (age, race/ethnicity, education, partner status, child rearing status, and daily injection), and for recent sex exchange behavior given the strong association with sexual minority status. Stata11 was used for analysis.

Findings

Of 307 participants, 4% identified as lesbian, 13% as bisexual, and 83% heterosexual. Thirty-five percent of sexual minority women reported a female sex partner in the past 90 days, compared to 2% of heterosexually identified women. Among women with a female sex partner in the past 90 days, 86% identified as sexual minority and 14% as heterosexual.

The study sample was majority (83%) African-American with average age of 41. Approximately half (45%) had completed high school, 75% had a current main partner, 30% were currently raising a child under 18, and many reported social instability (unemployment, homelessness, incarceration, low income status) in the past year.

Results of bivariate and multivariate analyses are presented in Table 1. In adjusted models, sexual minority women were significantly younger than heterosexual women. There were no significant differences in type or frequency of drug use.

Table 1. Bivariate and multivariate GEE analyses of factors associated with sexual minority status among female injection drug users in the STEP study (n=307).

Characteristic	Heterosexual (n=256)	Lesbian or bisexual (n=51)	Unadjusted Odds Ratios (95% C.I.)	Adjusted Odds Ratiosa (95% C.I.)
Socio-demographic and health – n (%)
Age – mean (S. D.)	41.5 (7.4)	37.5 (7.2)	0.93 (0.90, 0.97) **	0.92 (0.88, 0.98) **
Currently homeless	24 (9.4)	12 (23.5)	2.86 (1.30, 6.27) **	1.74 (0.69, 4.39)
Raising children under 18	80 (31.3)	10 (19.6)	0.54 (0.26, 1.13)	0.61 (0.29, 1.32)
Income $500 or more per month	102 (40.3)	27 (52.9)	1.71 (0.96, 3.06)	2.19 (1.15, 4.18) *
Received food stamps past 30 days	111 (43.4)	14 (27.5)	0.50 (0.26, 0.96) *	0.54 (0.26, 1.13)
Money from selling drugs in past 30 days	28 (10.9)	13 (25.5)	2.88 (1.38, 6.00) **	1.71 (0.77, 3.83)
Sex for money or drugs in past 90 days	78 (35.1)	30 (63.8)	3.26 (1.75, 6.05) ***	3.03 (1.52, 6.07) **
Paid money or drugs for sex past 90 days	16 (7.2)	11 (23.4)	3.93 (1.77, 8.76) **	2.78 (1.16, 6.71) *
Arrested in past year	102 (39.8)	30 (58.8)	2.12 (1.16, 3.88) *	1.11 (0.54, 2.30)
Incarcerated 6 mo. or more in past 10 yrs	62 (24.2)	30 (58.8)	4.38 (2.38, 8.07) ***	4.07 (2.07, 8.02) ***
Daily injection drug use	143 (55.9)	35 (68.6)	1.75 (0.91, 3.35)	1.00 (0.47, 2.13)
Shooting gallery in past 6 months	68 (26.6)	23 (45.1)	2.32 (1.27, 4.26) **	1.79 (0.90, 3.55)
Overdose ever	99 (38.8)	30 (58.8)	2.22 (1.22, 4.06) **	2.31 (1.15, 4.67) *
Hospitalized for mental illness among those ever diagnosed (n=174)	68 (48.2) (n=141)	28 (84.9) (n=33)	6.00 (2.19, 16.40) ***	5.99 (1.95, 18.38) **
Diagnosed with STD in past 3 months	7 (2.7)	5 (9.8)	3.82 (1.17, 12.46) *	4.00 (1.19, 13.45) *
Diagnosed with hepatitis B	14 (13.1)	8 (30.6)	3.26 (1.32, 8.08) *	2.88 (1.18, 7.01) *
Social resources -- Mean (S. D.)
Total size kin network	3.4 (2.6)	2.7 (2.0)	0.88 (0.78, 1.01)	0.92 (0.79, 1.07)
Total size emotional support network	2.11 (1.62)	1.69 (1.26)	0.81 (0.63, 1.03)	0.77 (0.57, 1.04)
Total size material support network	2.2 (1.7)	1.7 (1.2)	0.80 (0.64, 1.00) *	0.71 (0.51, 0.98) *
Total size financial support network	1.8 (1.5)	1.3 (0.8)	0.72 (0.56, 0.92) **	0.69 (0.52, 0.90) **
Total size socialize with network	2.4 (2.1)	1.9 (1.3)	0.84 (0.70, 1.00) *	0.80 (0.65, 0.99) *
Total size health advice network	0.9 (0.1)	0.6 (0.6)	0.79 (0.63, 1.00)	0.66 (0.46, 0.94) *
Total size support network	4.3 (2.7)	3.6 (1.8)	0.88 (0.78, 1.00)	0.86 (0.73, 1.00) *
Mean trust	7.7 (1.7)	7.2 (1.7)	0.85 (0.73, 1.01)	0.90 (0.74, 1.09)
Network density	0.5 (0.3)	0.5 (0.2)	0.37 (0.12, 1.12)	0.98 (0.26, 3.76)

^aEach model adjusted for age, race/ethnicity, education, daily drug injection, steady partner, child raising, and sex exchange

^***p<0.001

^**p<0.01

^*p<0.05

Approximately 25% of sexual minority women were currently homeless compared to 9% among heterosexual women, but this difference was not significant in the final adjusted model. Their employment status did not differ from heterosexual identified women, but they were more likely to have income higher than $500 per month. Their income sources were three times as likely to include trading sex for money or drugs. They were also almost three times as likely to report providing money for drugs or sex in the past 90 days. They were similarly likely to report a recent arrest, but more likely to report arrests for prostitution/solicitation (27%) or drug distribution (23%) in the past year compared to their heterosexual counterparts (8% and 7%, respectively). Sexual minority women were more likely to report extended incarceration during the past ten years and close to 60% reported an arrest in the past year. Only 6% of sexual minority women reported no time in prison in the past ten years and the majority (60%) had spent at least six months, compared to 28% and 24% of heterosexual women. Among those women who had been diagnosed with a mental illness, sexual minority women were approximately six times as likely to report associated hospitalization.

We examined a range of injection risk behaviors, including injection with a used syringe, cooker, cotton, water, and found no significant differences. However, sexual minority women were more than twice as likely to report having ever overdosed. There were also no significant differences in HIV status. Sexual minority women were almost four times as likely to report a recent sexually transmitted disease and almost three times as likely to report a hepatitis B diagnosis in bivariate analysis.

We also examined whether social network characteristics and resources provided any additional insight into potential differences by sexual minority status. Overall, social network characteristics did not vary substantially between sexual minority and heterosexual women. Network size, emotional support, size of family networks, trust within networks, and network density were similar. However, sexual minority women reported fewer individuals who would be willing to provide material or financial support, fewer people to socialize with, and fewer people who could provide health advice.

Discussion

These findings support prior research showing high prevalence of social and health disparities among sexual minority women, particularly those further marginalized by injection drug use status. Yet this research additionally provides evidence that these disparities are evident when examined by one's identity as a lesbian or bisexual woman, rather than based on behaviorally defined sexual minority categorization. The finding that only a third of women had a female sex partner in the past 90 days reinforces the need to examine identity in addition to behavior, as a study with a behavioral definition of sexual minority status would have missed 65% of this sample.

These data were collected as part of an intervention study among IDUs; data collection and recruitment procedures were not designed to specifically facilitate involvement of sexual minority female IDUs. Thus, it is possible that those who opted to participate may differ from others. These findings may also be limited by self-report bias despite use of ACASI for collection of HIV risk data, extensive training in rapport building among the experienced research staff, and attention to creating a comfortable, respectful, and professional research environment. It is possible that participants may have under-reported sexual minority status or other socio-demographic or behavioral characteristics.

Female injection drug users often experience added social marginalization and stigma compared to male drug users ^11,12. While services unique to the needs of female drug users have expanded over time, relatively few are designed to address the particular needs of sexual minority women who inject drugs. In contrast to men, many HIV-related programs for women do not ask, collect information on, or address sexual minority status among participants, which further contributes to social marginalization among these women ⁸. Similar to prior studies, these findings highlight social characteristics and sexual risk behaviors that warrant attention in HIV prevention and other health promotion services for this population, particularly among those engaged in sex exchange behaviors ^2,5. Furthermore, the use of shooting galleries for injection introduces contextual and setting specific risks that may facilitate disease transmission.

Overall, these data support a need for attention to social marginalization, social support, and psychosocial issues among sexual minority women, even within other socially marginalized communities. Furthermore, there is a need for research with large enough samples to further examine differences among sexual minority female IDUs, such as between bisexual and lesbian women. Women in this study reported substantial homelessness and have experienced lengthy incarceration compared to their heterosexual counterparts, as has been seen in earlier studies of WSW. Their income sources were also strongly composed of illicit sources, further increasing likelihood of future incarceration, and they had fewer economic and health-related support resources within their networks. Recent studies have revealed high and understudied prevalence of poverty within the LGBT community, particularly among bisexual women ¹³, and evidence of social network and support differences among sexual minority women ¹⁴. There is a strong need to identify and address contributing factors to socioeconomic and social network marginalization among lesbian and bisexual women and a particular need to understand factors contributing to disproportionate engagement in illicit income generation activities which enhance risk for HIV and incarceration, especially sex exchange behaviors.