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Increased Sexual Risk Behavior and High HIV Seroincidence among Drug-Using Low-Income Women with Primary Heterosexual Partners James M. McMahon, Ph.D.1 Stephanie Tortu, Ph.D.2 Enrique R. Pouget1 Rahul Hamid1 Leilani Torres1 1 2 National Development & Research Institutes, New York, NY Tulane University School of Public Health & Tropical Medicine, New Orleans, LA Funding provided by NIH/NIDA grants R01DA10864, R01DA12805 and R01DA15641 Study Background & Objectives: • Heterosexual transmission of HIV continues to rise among women in many parts of the world. • Previous research has shown that characteristics of sexual partnerships have an important influence on HIV risk among women. • This study examined HIV risk among women drugusers in East Harlem, NYC, to assess women’s relative risk from different types of sexual partners. • The findings from this study will help inform the development of HIV prevention programs tailored to women’s specific risk partnerships. Study Setting: East Harlem, NYC Population size: Total 117, 000 Racial/Ethnic Composition: Hispanic 52% Black Non-Hispanic 36% White Non-Hispanic 7% Social/Health Statistics: Completed high school 56% Unemployed 17% Receive public assistance 37% Income below poverty line 40% HIV seroprevalence 4.8% Infant mortality rate 9.7 per 1000 births Hospitalizations due to drug use 724 per 100,000 East Harlem (“El Barrio”), New York City: East Harlem HIV Risk Studies Involving Drug-Using Women and Heterosexual Couples Study I (DUSC) Study II (CAR) Women Drug Users in Social Context S. Tortu, PI A. Neaigus, Co-I Couples at Risk Time frame 1996 - 1999 2000 - 2003 Sample 601 drug-using women 353 drug-using women and their primary partners Eligibility >18; female; current use of crack, cocaine or heroin (IDU or non-IDU); sexually active >18; female and male primary partners; current use of crack, cocaine or heroin (IDU or nonIDU); sexually active Recruitment Street-recruited, clientreferral Female targeted, streetrecruited, client-referral Data collection Survey on demographics, health, sex & drug risk, risk context & partnerships; all offered HIV, HBV, HCV counseling and testing Study S. Tortu, PI J.M. McMahon, Co-I DUSC & CAR Sample Descriptors Study I (DUSC) N= 601 women Study II (CAR) N= 353 couples Black Non-Hispanic: Hispanic: White Non-Hispanic: 55% 39% 6% 40% 44% 13% Median Age: Completed High School: Unemployed: Homeless: 39 49% 88% 12% 40 F: 47% M: 60% 87% 16% crack: Non-IDU cocaine: heroin: 60% 29% 46% F: 56% M: 46% 24% F: 50% M: 44% IDU (mostly heroin): 27% 37% HIV and Hepatitis B and C Seroprevalence Pathogen HIV HBV HCV Study I Study II Study II Women Women Men 23.3% 22.1% 22.0% (119/510) (74/335) (75/341) 52.4% 43.1% 47.8% (220/420) (128/297) (144/301) 43.1% 51.5% 52.7% (182/422) (153/297) (159/301) Operational Definitions of Sexual Partnerships: • Primary Male Partner (PMP): Legal or common-law husband or steady primary boyfriend of at least one year. • Sex Exchange Partner: A sexual partner with whom sex was exchanged directly for money or drugs. • Casual Sex Partner: A sexual partner who is neither a primary nor exchange partner (e.g., one-time sex partner or regular casual sex partner). Concurrent Sexual Partnerships (DUSC n=601): Prior 6 months self-reported 71% 46% Primary 41% Casual 11% 16% 6% 8% 13% Exchange 5% 32% Percent Consistent Condom Use by Partner Type Studies on U.S. Urban Populations Location/Source Primary Casual Exchange Time Frame East Harlem (Tortu-DUSC) 25 43 75 Last intercourse East Harlem (Tortu-CAR) 22 - - Philadelphia (Watkins) 27 52 80 Washington, DC (Williams) 20 52 61 N. California (Ruiz) 30 51 - East Harlem (Tortu-DUSC) 23 - - East Harlem (Tortu-CAR) 19 43 65 Birmingham (Cabral) 24 - - U.S. Multisite (Harvey) 24 - - Seattle (Baker) 14 26 - Last 30 days Last 3 months Cumulative Unprotected Vaginal Sex (DUSC n=601): By Partner Type (12 months) 120,000 102,770 100,000 80,000 60,000 40,000 17,980 20,000 7,220 0 Primary Casual Exchange Cumulative Unprotected Anal Sex (DUSC n=601): By Partner Type (12 months) 1,400 1,220 1,200 1,000 800 600 400 200 5 15 Casual Exchange 0 Primary Unprotected Sex by Male+/Female- Couples By Women’s Awareness of Partner’s HIV Status (CAR, n=39) 80 70 60 50 69% 44% Unaware 40 31% 30 20 25% 56% Aware 75% 10 0 Unprotected sex (last 30 days) Consistent Condom Use Women’s Injection Practices Last Injection Event (DUSC, n=185) Social/Safe Receptive Sharing w/ Primary Partner 30% Unsafe 11% Solitary 95% 59% Solitary: Woman injected alone Social: Women injected with other IDUs Women’s Relative Risk of Acquiring HIV from Different Types of Sex Partners Risk from PMPs: More common Lower condom use More freq. exposure Single Partner Risk from Non-PMPs: Less common Higher condom use Less freq. exposure Multiple partners Mathematical Modeling: HIV Seroincidence Estimated from Self-Reported Risk Behavior and HIV Transmission Parameters Primary male partner P Male-to-Female Transmission Probability per Act: Vaginal intercourse (.001) Anal intercourse (.02) Syringe sharing (.01) Probability of Risk Partner Being Infected: 0 to 1.0 depending on partner type and characteristics Condom Use: Rate of effectiveness (.90) Number of Partners By partner type Subject: uninfected female druguser C S Casual sex partner X Exchange sex partner F Friends, family, running buddy 1. Individual Probability (P) of HIV Seroconversion: Bernoulli equations applied to each individual in the sample to calculate probability of HIV seroconversion based on self-reported risk behavior. 2. HIV Seroincidence: Sample mean P used to calculate model-based estimate for seroincidence over the entire sample (number of seroconversions per 100 person years). Model-Predicted HIV Incidence (DUSC, n=390) Seroconversions per 100 person-years Rate: Total sample of 390 HIV- women # of infections: 2.77 11 From primary partner 2.13 8 From casual partner 0.18 1 From exchange partner 0.46 2 Estimated HIV Seroincidence (DUSC & CAR, n=651) Seroconversions per 100 person-years Rate: Rel Risk: Model-Predicted HIV Incidence From primary partner (subset n=575 with PMPs) 2.54 Ref. From casual partner (subset n=79 with casual partners) 1.06 -2.40 From exchange partner (subset n=122 exchangers) 1.36 -1.87 Actual Observed HIV Incidence Cohort of repeat testers from DUSC & CAR: 4 seroconversions of 52 women with PMPs over 3.22 yrs 2.48 (95% CI: .07, 6.35) Conclusions: • Drug-involved women from East Harlem, New York City… • …exhibit one of the highest rates of HIV infection in the United States • …are at greatest risk of acquiring HIV from primary male partners • …continue to engage in sex- and drug-related HIV risk behavior with infected or high-risk male partners • Preliminary data suggest a high rate of HIV seroconversions among women drug-users with PMPs • Interventions promoting “monogamy” may not help these women avoid disease due to the high risk of acquiring HIV from primary male partners Acknowledgements: This work was supported by research grants from the U.S. National Institutes of Health/National Institute on Drug Abuse (R01DA10864, R01DA12805 and R01DA15641). The authors thank the dedicated staff (former and present) of the DUSC, CAR & CHIP projects: Sherelle Bonaparte, Jeanine Botta, Hanifah Burns, Jeanne Campbell, Audrey Grandy-Lampkin, Robert Quiles, William Rodriguez, and Lee Wengraf. We also thank the men and women who participated in the DUSC and CAR studies.