Download Intimate Partner Violence & HIV

Crack Cocaine, HIV, and
African American Women
Alison Hamilton, Ph.D.
[email protected]
UCLA Department of Psychiatry
Integrated Substance Abuse Programs
November 5, 2008
HIV Incidence
• In 2005, 49% of those diagnosed with
HIV/AIDS were African American (including
children), though African Americans make up
only 13% of the US population
• In 2004, women accounted for 27% of new HIV
infections
• Among women living with HIV/AIDS in 2005,
64% were African American
• Source of infection for women: 78% of new
infections due to heterosexual contact
African Americans & HIV
• For African American women, the most
common ways of getting HIV are having
unprotected sex with a man who is
infected, and sharing injection drug works
with someone who is infected
• Those at higher risk are: unaware of their
partner’s status, infected with other STDs,
and/or living in poverty
• Useful fact sheet:
http://www.cdc.gov/hiv/topics/aa/resources
/factsheets/pdf/aa.pdf
African American
Women & HIV
• In a 2004 study, women who used crack cocaine
were less likely (than women who did not) to take
antiretroviral medicines as prescribed
• High rate of other STDs among African Americans:
can increase chances of HIV infection by 3-5x
• Women living in SPA 6 (South) have 2-3x
higher chlamydia, gonorrhea and primary
and secondary syphilis rates compared to the
overall rates for women in Los Angeles County.
• Los Angeles County public health report:
http://publichealth.lacounty.gov/wwwfiles/ph/hae/ha
/WomensHealthIndicators05.pdf
Women’s Circumstances
• Demographic (age, education, etc.) and
structural barriers (homelessness, poverty, etc.)
affect a woman’s ability to change life
circumstances
• Childhood histories of abuse and drug use
common among crack cocaine users 
disempowered adult relationships
• Historical issues & contextual factors may
especially jeopardize poor African American
women who are already at greater risk for HIV
infection
Intimate Partner Violence
(IPV) & HIV
• Recent attention being paid to IPV
• Annually, 1.5 million women raped or physically
assaulted by intimate partner
• Lifetime rates of IPV between 21-55%
• “Gender-based violence” among pregnant
women and HIV+ women ranges from 8%-38%
• SEVERAL WAYS IN WHICH HIV & IPV
INTERSECT
– Often those with high rates of IPV are same groups
also at high risk for HIV (young women, drug users,
women living in poverty)
Abuse & Fear
(coercion & control)
increase RISK for
HIV transmission
Intimate
Partner
Violence
HIV-positive women
may experience IPV
as RESPONSE to
disclosure of infection
Comparing HIVand HIV+ women
• Higher severity of IPV among HIV+
women
• HIV+ women experience more frequent
abuse and report more severe trauma
histories
• Cumulative violence: 2 or more types of
violence = 5x more likely to have recent
STI
Women Who Use Crack
• Crack-using women are an important group affecting the
HIV epidemic in their communities because of the high
risks of becoming infected as well as transmitting to
others
• Subpopulations engage in high-risk sexual activities
(e.g., exchange of sex for money and drugs)
• Crack cocaine use is associated with both delayed entry
into HIV primary care and reduced medication
adherence
• HIV+ crack-using women are likely to have high viral
loads and are at high risk of transmitting HIV to sexual
partners
• Use of crack cocaine associated with high rates of
sexually transmitted infections and vaginitis, which
increase the potential for HIV transmission
What Research Has Found
Women crack users with multiple partners differed from
women with single partners as they are more likely to:
• Be homeless
• Be financially dependent
• Have experienced a difficult childhood
• Have much heavier drug use (higher rates of daily
alcohol use and crack use, longer crack runs, higher
doses of crack)
• Have symptoms of depression, anxiety, and PTSD
But women with single partners had more unprotected
sex, so they are also at risk; 62% believed they were at
risk for HIV (88% of women with multiple partners
believed they were at risk)
What Research Has Found
HIV-positive persons who use crack cocaine
engage in sexual risk behaviors at relatively high
rates and may be at an especially high risk for HIV
transmission or re-infection.
•In a study of 10,415 HIV-positive heterosexual men,
heterosexual women, and men who have sex with
men, Campsmith et al. found that those who
continued to use crack after HIV diagnosis (n = 2,361)
reported the highest prevalence of unprotected sex,
multiple partners, and exchanging sex for drugs or
money regardless of sexual orientation and gender.
What Research Has Found
Among 303 African-American, HIV-positive users:
• 51% reported a recent crack binge (typical crack binge =
3.7 days and smoking 40 rocks)
• Nearly two-thirds reported their last binge was in their own
or another’s home
• 72% had sex during the last binge, with an average of 3.1
partners
• Recent bingers were more likely than non-bingers to
consider themselves homeless, to not have any income
source, to have used crack longer, and to score higher on
risk-taking and need for help with their drug problem
• Recent bingers had more sex partners in the last six
months and in the last 30 days and were more likely to
have never used a condom in the last 30 days.
• Among both male and female users, recent bingers were
more likely to report lifetime trading of sex for drugs.
What Role Can Drug
Treatment Play?
Large study conducted over 8 years with 1,658
drug-using women (57.5% African, 80.3% HIV
positive; 49.6% crack/cocaine users):
•Drug treatment was not associated with
subsequent consistent condom use, regardless of
frequency of attendance, but involvement in at least
three treatment programs was related
Additional efforts are needed to integrate effective
sexual risk reduction programs into drug treatment
settings; expanding access to different types of drug
treatment modalities may be indicated.
Best-Evidence Interventions
Wechsberg & colleagues:
• Sample = Out-of-drug-treatment African American women (n = 620)
who use crack
• Only woman-focused intervention participants consistently improved
employment and housing status
• Woman-focused intervention participants were least likely to engage in
unprotected sex
Sterk & colleagues:
• Sample = 71 African American women who injected crack
• Substantial decreases in the frequency of drug use and the frequency
of drug injections; sharing of injection works or water; number of
injections.
• Trading sex for drugs or money, having sex while high, as well as other
sexual risk behaviors were also reduced significantly
• Women in both enhanced intervention conditions were more likely to
reduce their drug using and sexual risk behaviors than women in the
standard condition.
Interventions for
HIV & IPV risk
• No studies specifically designed to
reduce both risk of HIV and IPV  no
best practice evidence
• Consider “sexual risk reduction hierarchy”
- provide women with a range of options
offering varying levels of protection
• Need multisystem involvement and
collaboration with perpetrators’ programs
Summary
• Disproportionate prevalence and incidence of HIV/AIDS
in African Americans
• African American women significantly affected by HIV &
other STDs
• African American women who use crack at significant
risk for HIV infection, and HIV+ women at significant
risk for not getting needed services and maintaining
medication regimens
• Risk is complicated by structural barriers and
interpersonal barriers such as intimate partner violence
• Some interventions are promising for reduction of
sexual risk, but few address structural barriers and the
combined set of risk factors that many women face on a
daily basis