The study found multiple significant associations between an individual's HIV risk behavior and HIV risk and protective characteristics of his social network. These associations suggest multiple ways in which social networks might influence risk behaviors of members as well as facilitate positive peer norms regarding HIV/AIDS prevention. Joint risk activities between the participant and his network were apparent. Over one fifth of the alters had sex with the participant, and less than one quarter consistently used condoms during these encounters.
The findings indicate that a large number of the participants and their alters talked to each other about HIV/AIDS risks and encouraged each other to use condoms. These findings suggest that, on the whole, the social networks cultivated positive peer norms about condom use and raised awareness about HIV/AIDS. The widespread presence of these positive norms is somewhat at variance with other studies. For example, Smith, Lucas, and Latkin27
found that HIV is an infrequent topic of conversation among drug users.
Different network structural characteristics were associated with HIV risk factors as found in other studies.5,8
A larger network was found to increase the likelihood that the participant had more than one sexual partner in the past 6 months. Higher connectedness among alters within a network (i.e., density) was found to decrease the likelihood of the following: engaging in unprotected sex among participants, having more than one sexual partner in the past 6 months and trading sex for money or drugs. These findings are inconsistent with previous studies of drug users that have identified higher density in networks as a risk factor for engaging in sexual HIV transmission behaviors.5,8
The inconsistency may have occurred because this sample was drawn from MMTP patients with primary steady partners, and the type of name generator used may have been different. The association between a high density network and low sexual risk factors may further suggest the widespread presence of positive norms regarding condom use and HIV/AIDS prevention, as those who are in more connected networks have more opportunities to exchange information and advice related to HIV/AIDS risk reduction.
The findings of the adjusted logistic regression analyses suggest that higher levels of perceived sexual risk among alters were associated with an increased likelihood of the participant engaging in sexual risk behaviors. This supports the findings from other research on how sexual risk behaviors among individuals in a social network can be influenced by the norms.5,8
Networks with a higher number of alters who were perceived as having more than one sexual partner in addition to the participant were associated with an increased likelihood that the participant had more than one partner and engaged in sex trading. This finding suggests that perceived sexual risk of alters may influence sexual risk behaviors of the participant. Networks with a higher number of alters whom the participant reported as ever having had sex with an HIV positive person or an IDU was associated with an increased likelihood that the participant was HIV positive, traded sex, and had sex with someone who is HIV positive and/or an IDU. This finding similarly suggests that the high number of alters who are perceived as ever having had sex with a risky partner may increase the likelihood of an array of sexual risk factors among participants. Not surprisingly, the higher number of alters whom the participant reported as being HIV positive was associated with an increased likelihood that the participant was HIV positive, as well as had sex with an IDU and/or HIV positive partners. The findings suggest that HIV positive individuals tend to connect more with other HIV positive individuals for social support. The serological matching by positive HIV status may also occur as a risk reduction strategy to lower sexual and drug-related transmission to uninfected individuals. Alternatively, the finding linking the higher number of HIV positive alters to having had sex with an HIV positive partner may be explained by the direct effect of the HIV positive alter having sex with the participant.
The multivariate findings further suggest mixed associations between positive network influence factors and sexual risk outcomes among participants. Participants who indicated that they exchanged encouragement to use condoms with more alters in their network were less likely to report engaging in unprotected sex. Similarly, participants who indicated that they talked about HIV/AIDS risks with a larger number of alters in their network were less likely to engage in unprotected sex in the past 6 months. These findings suggest that peer norms for HIV risk reduction have a beneficial impact on reducing the participant's likelihood of engaging in unprotected sex. Conversely, a higher number of alters who talked with the participant about HIV/AIDS risks was associated with trading sex in the past 6 months. This negative association suggests that alters may be targeting their HIV risk reduction messages to participants who are at higher risk of sexual transmission by virtue of their having multiple sexual partners. It is not surprising that alters are less likely to encourage participants in long-term monogamous relationships to use condoms. Collectively, these findings support the notion that networks constitute a mechanism for HIV risk behavior norms or change.13
Limitations of the Study
The study has several limitations: (1) this study does not address causality; data used in this paper were collected at a single point in time; (2) data on the network were reported by the participants and not corroborated with the alters; and (3) the generalizability of study findings to other MMTP populations is somewhat limited due to the fact that more than a third of the random sample refused to participate or could not be located, and eligibility criteria excluded men without intimate partners. Despite these limitations, the findings have important HIV prevention implications.
Implication for HIV Prevention Interventions
During the past decade a number of drug abuse researchers have established that networks are critical determinants of HIV risks and have developed effective community-based HIV prevention intervention models to reduce these risks.23,28,29
This study's findings provide information on a profile of networks of men in MMTPs that is essential in the development of network and community level HIV interventions.
The study suggests that network members may directly influence a participant's sexual behavior by virtue of engaging in risky sexual behavior with participants, or they may have a broader social influence by serving as negative or positive role models with regard to engaging or not engaging in HIV risk behaviors or by socially interacting with participants to create positive peer norms around HIV risk reduction. Social networks of men in MMTPs can be used to facilitate discussions and encourage HIV risk reduction. HIV prevention approaches must consider the different aspects of social networks that may be harnessed in promoting risk reduction. Several studies found that using network members to promote discussion on condom use or family planning are effective mechanisms in promoting change in norms and sexual risk behaviors.30–32
Network influence, for example, has been used successfully in a study in Tanzania that was designed to promote HIV prevention through a campaign designed to increase community-wide talk about HIV and family planning.32
In another study, Kelly et al.33
used opinion leaders to teach individuals in the gay community to encourage condom use.
As suggested earlier, the study findings suggest that social networks can cultivate positive peer norms around HIV risk reduction and exert a positive influence on the protective behaviors of members. The findings also indicate that denser networks may lend themselves to a more efficient spread of HIV prevention messages among this population of men in MMTPs. The efficacy of network interventions may be enhanced by facilitating opportunities to increase positive interactions among network members around the need to protect themselves and their community from HIV/AIDS.
To date, only a limited number of effective network HIV prevention intervention models have been designed for men in MMTPs. Most HIV prevention interventions target the individuals without much emphasis on the social contexts, including the networks and their roles in encouraging healthy, safe behaviors and discouraging risk. Moreover, in MMTPs, most counseling, treatment modalities, and services are guided by individual approaches, and peer approaches are rarely employed. Network approaches in MMTPs would require a paradigm shift in the treatment, counseling, and services for men in drug programs. This paradigm shift would require training of drug treatment staff on network profiles of the drug-involved men, the roles and influences of networks on HIV norms, risk taking and reduction, models of assessment that evaluate networks, and network-oriented treatment modalities. The findings of this research may inform researchers and clinicians on the profile of the networks and on the importance of considering the networks in HIV intervention prevention approaches for drug-involved men.