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Marital Status and Sexually Transmitted Infection Risk Among Non-Injection and Injection Drug Users
M.R.
1
Khan, J.D.
1
Scheidell,
C.
3
Gaydos, A.M.
1
Coatsworth,
W.W.
2
Latimer
1Department
of Epidemiology, College of Public Health & Health Professions and College of Medicine, University of Florida
2Department of Clinical and Health Psychology, College of Public Health & Health Professions, University of Florida
3Division of Infectious Diseases, School of Medicine, Johns Hopkins University
BACKGROUND
•
•
•
RESULTS
In US general population samples, being married is associated with protection
against multiple and concurrent partnerships (Taylor, Adimora, & Schoenbach,
2010; Adimora et al., 2002), important determinants of sexually transmitted
infection (STI), and against STI and HIV infection (Bauer et al., 2010; Dunne
et al., 2011; Radcliffe et al., 2001).
However, married individuals are less likely to use condoms than unmarried
individuals in both general population and high-risk samples (Anderson, 2003;
Stein et al., 2007), suggesting some behavioral risk factors for STI are
elevated in this population.
The potential role of marriage in protecting against STI risk behaviors and
infection in high-risk populations such as drug users is not well understood.
?
Marital Status in
High-Risk
Populations
Multiple,
Concurrent
Parttnerships
?
Non-monogamy
?
?
Trichomoniasis
Infection
Sex Trade
Condom Use
Table 1. Sample Characteristics and Marital Status (n=275)
Number (%)
Sex
Male
Female
116 (42.3)
158 (57.7)
% Single
55.7
68.6
% Divorced
31.3
23.7
% Married
13.0
7.7
P value
0.0791
Race
White
Non-white
34 (12.4)
241 (87.6)
48.5
64.9
48.5
23.9
3.0
11.3
0.0078
Age
27 Years or Younger
28-34 Years
35-40 Years
41 Years or Older
72 (26.2)
71 (25.8)
72 (26.2)
60 (21.8)
78.3
71.8
47.2
53.3
13.0
16.9
40.3
38.3
8.7
11.3
12.5
8.3
0.0007
Education
<High School/GED
≥High School/GED
111 (40.5)
163 (59.5)
72.7
55.9
17.3
33.5
10.0
10.5
0.0091
Cigarette Smoking
Yes
No
228 (85.1)
40 (14.9)
62.2
65.0
26.7
27.5
11.1
7.5
0.7907
Crack Smoking
Yes
No
93 (34.1)
180 (65.9)
65.2
58.7
23.6
32.6
11.2
8.7
0.2686
Marijuana Use
Yes
No
97 (23.4)
177 (64.6)
64.2
62.5
25.3
27.3
10.5
10.2
0.9381
a Adjusted
for age, race, gender, education, cigarette and crack smoking in the past 6 months
b Adjusted for age, race, gender, education, cigarette smoking, crack smoking, marijuana use and binge
drinking in the past 6 months
METHODS
Data Source
• Baseline data were derived from the
Neuro-HIV Intervention Study, an
RCT that assesses the efficacy of
an intervention focused on
neuropsychological and behavioral
risk factors as a means to reduce
infectious disease outcomes among
non-injection and injection drug
users in Baltimore, Maryland.
Population
• 275 participants with STI outcome
data
Measures
Independent Variable:
• Marital status (single, divorced, or
married)
Outcomes (Dichotomous):
• Trichomoniasis infection
• Ever had concurrent casual sex
partners within a 3 month period
• Elevated lifetime number of casual
sex partners, defined being in the
top quartile for number of casual
partners
• Respondent’s non-monogamy in the
past 6 months
• Partner’s non-monogamy in the past
6 months
Measures (continued)
• Inconsistent condom use
defined as <100% condom use
with a steady partner in lifetime
• Lifetime history of sex trade
involvement, defined as buying
or selling sex
Covariates:
• Gender
• Age
• Education
• Race
• Cigarette smoking*
• Crack Use*
• Marijuana use*
• Binge Drinking*
*Use in the past 6 months
Analyses
• We calculated unadjusted and
adjusted odds ratios (ORs) and
95% confidence intervals (Cis)
for the associations between
marital status and outcomes.
• We evaluated the degree to
which the association between
marital status and
trichomoniasis infection was
attenuated upon adjustment for
sexual behaviors hypothesized
to mediate the association.
Table 2. Crude and Adjusted Odds Ratios of Trichomoniasis and Sexual Risk
Behaviors by Marital Status
Outcomes
Trichomoniasis Infection
Single
Divorced
Married
Concurrent Casual Sex Partner
Single
Divorced
Married
Elevated Number of Casual Sex Partners
Single
Divorced
Married
Respondent’s Non-Monogamy**
Single
Divorced
Married
Partner’s Non-Monogamy**
Single
Divorced
Married
Sex Trade Involvement
Single
Divorced
Married
Inconsistent Condom Use
Single
Divorced
Married
Lifetime Casual Partners
Single
Divorced
Married
Unadjusted
OR (95% CI)
Adjusteda
OR (95% CI)
16.7
17.8
32.1
1. (referent)
1.06 (0.52, 2.18)
2.32 (0.95, 5.64)
1.0 (referent)
1.31 (0.49, 2.61)
2.90 (1.04, 8.12)
1.0(referent)
1.13 (0.48, 2.70)
2.97 (1.03, 8.51)
16.0
17.1
44.4
1. (referent)
1.09 (0.52, 2.29)
4.21 (1.77, 9.98)
1.0 (referent)
1.00 (0.43, 2.36)
4.33 (1.64, 11.44)
1.0 (referent)
1.01 (0.43, 2.40)
4.31 (1.63, 11.41)
26.3
24.7
39.3
1. (referent)
0.98 (0.51 (1.86)
1.76 (0.76, 4.08)
1.0 (referent)
0.83 (0.39,0.74)
1.26 (0.50, 3.23)
1.0 (referent)
0.85 (0.40, 1.80)
1.22 (0.47, 3.16)
19.1
7.1
25.9
1.0 (referent)
0.33 (0.12, 0.88)
1.49 (0.58, 3.82)
1.0 (referent)
0.35 (0.12, 0.98)
1.33 (0.50, 3.59)
1.0 (referent)
0.36 (0.12, 1.02)
1.31 (0.48, 3.58)
8.8
9.6
10.7
1.0 (referent)
1.21 (0.47, 3.12)
1.26 (0.34, 4.70)
1.0 (referent)
1.14 (0.39, 3.30)
1.61 (0.41, 6.40)
1.0 (referent)
1.14 (0.39, 3.31)
1.57 (0.40, 6.25)
39.2
35.6
46.4
1.0 (referent)
0.91 (0.52, 1.61)
1.33 (0.60, 2.98)
1.0 (referent)
0.79 (0.41, 1.52)
1.57 (0.66, 3.72)
1.0 (referent)
0.80 (0.41, 1.55)
1.55 (0.65, 3.70)
90.9
91.3
96.3
1.0 (referent)
1.05 (0.40, 2.83)
2.60 (0.33, 20.52)
1.0 (referent)
0.78 (0.26, 2.40)
2.29 (0.28, 18.67)
1.0 (referent)
0.76 (0.25, 2.30)
2.40 (0.29, 19.53)
% with Outcome
Mean
Fully-Adjustedb
OR (95% CI)
Mean Difference
between Married
and Single
P value
7.4
0.0914
9.8
12.8
17.2
Table 3. Mediation of Association between
Marital Status and STI by Sexual Risk
Marital Status
Single
Divorced
Married
Fully-Adjusted OR b
1.0 (referent)
1.13 (0.48, 2.70)
2.97 (1.03, 8.51)
Fully Adjusted Model Plus Additional Adjustment for
Hypothesized Causal Intermediate(s)
Concurrent Casual Sex Partners
1.0 (referent)
Single
1.17 (0.52, 3.09)
Divorced
4.02 (1.27, 12.65)
Married
High Number of Partners
1.0 (referent)
Single
0.39 (0.75, 2.43)
Divorced
2.26 (0.75, 6.75)
Married
Respondent’s Non-Monogamy
1.0 (referent)
Single
0.99 (0.40, 2.48)
Divorced
2.40 (0.79, 7.26)
Married
Partner’s Non-Monogamy
1.0 (referent)
Single
0.88 (0.34, 2.23)
Divorced
2.60 (0.86, 7.87)
Married
Sex Trade Involvement
1.0 (referent)
Single
1.15 (0.48, 2.76)
Divorced
3.08 (1.06, 8.95)
Married
Inconsistent Condom Use
1.0 (referent)
Single
1.06 (0.44, 2.57)
Divorced
2.82 (0.97, 8.17)
Married
Adjusting for All Sex Risk
Variables
1.0 (referent)
Single
0.98 (0.38, 2.53)
Divorced
2.93 (0.88, 9.77)
Married
CONCLUSIONS
•
•
•
•
In this sample of drug users, married men and women experienced disproportionate levels of risk-taking behavior and infection with trichomoniasis compared with single and divorced individuals. These findings are inconsistent with results of generalpopulation surveys, which have suggested that marriage has protective effects against risk-taking and infection.
Elevations in previous and current partnership levels and non-monogamy among married individuals compared with non-married individuals appear to, in part, explain elevations in STI in this group.
An important limitation of the study is the cross-sectional design. Elevated levels of STI among married individuals could reflect acquisition of infection prior to becoming married or acquisition of infection while in a marital partnership.
Regardless, the results highlight the importance of STI screening and treatment in this drug-using population, not only among single individuals but also married individuals and their partners.
REFERENCES
Adimora, A. A., Schoenbach, V. J., Bonas, D. M., Martinson, F. E., Donaldson, K. H., & Stancil, T. R. (2002).
Concurrent sexual partnerships among women in the United States. Epidemiology, 13, 320-7.
Anderson, J.E. (2003). Condom use and HIV risk among US adults. American Journal of Public Health, 93(6),
912-914.
Bauer, G.R., Khobzi, N. & Coleman, T.A. (2010). Herpes simplex virus type 2 seropositivity and relationship status
among U.S. adults age 20 to 49: a population-based analysis. BMC Infectious Diseases, 10 (359), 1-10.
Dunne, E.F., Sternberg, M., Markowitz, L.E., McQuillan, G., Swan, D., Patel, S., & Unger, E.R. (2011). Human
papillomavirus (HPV) 6, 11, 16, and 18 prevalence among females in the United States—national health and
nutrition examination survey, 2003–2006: opportunity to measure HPV vaccine impact? The Journal of Infectious
Diseases, 204, 562-5.
Radcliffe, K.W., Ahmad, S., Gilleran, G. & Ross, J.D.C. (2001). Demographic and behavioral profile of adults
infected with chlamydia: a case control study. Sexually Transmitted Infections, 77, 265-270.
Stein, J.A., Nyamathi, A., Ullman, J.B. & Bentler, P.M. (2007). Impact of marriage on HIV/AIDS risk behaviors
among impoverished, at-risk couples: a multilevel latent variable approach. AIDS and Behavior, (111), 87-98.
Taylor, E.M., Adimora, A.A. & Schoenbach, V.J. (2010). Marital status and sexually transmitted infections among
african americans. Journal of Family Issues, 31(9), 1147–1165.
GRANT SUPPORT
This research was funded by a grant awarded to
William Latimer from the National Institute on Drug
Abuse (NIDA-R01 DA14498). All authors declare that
they have no conflict of interest.
CONTACT INFORMATION
Maria Khan, PhD
University of Florida
2004 Mowry Rd.
Office 4230
PO Box 100231
Gainesville, FL
Office Phone: 352.273.5366
Email: [email protected]