This study examined the relationship between drug use and HIV high risk sex behaviors among women in methadone maintenance (MM) and psychosocial outpatient (PS) treatment settings. In both samples, the overwhelming majority was engaged in high risk sexual behavior, at mean frequencies of about 20 unprotected occasions in the past 3 months. Because women in PS have been less studied, and because cocaine has been shown to play a role in HIV sexual risk behavior, there was a particular interest in the relationship between cocaine and sexual risk. Especially in the PS sample, cocaine use was significantly associated with an increase in high risk sex behavior, including risk of having multiple male partners, sex trade, sex with drugs or alcohol, and anal sex. Interestingly, the association was with a cocaine diagnosis, either abuse or dependence, and not with frequency of cocaine use. Thus, the association was increased by problem use, rather than any use. The substantial percentage of diagnoses of cocaine dependence within the past six months (58.3%) compared to a much smaller number reporting actual use within the past 30 days (19.5%) was notable. Since this was a treatment-seeking sample, this could explain the difference and may be a reflection of the participants’ motivation to change behavior.
In the PS sample, neither opiate use diagnosis was found to have the broad relationship with multiple sex risk variables seen for cocaine use diagnosis. A single significant association was found between opiate use diagnosis, as opposed to days of opiate use, and having multiple male partners. Indeed, while chronic opiate use is associated with diminished libido and sexual function, cocaine is associated with hypersexuality. A similar distinction was made in an earlier study of patients in residential treatment (6
) which highlighted the impulsivity effects of cocaine. Alcohol diagnosis was present in a third of the PS sample and associated with having multiple male partners and having sex with drugs or alcohol. Number of alcohol use days was positively associated with having sex with drugs or alcohol and of having anal sex. These findings, for both problem alcohol use and any alcohol use, suggest a somewhat broader influence of alcohol on sexual risk behavior than opiates, and closer to that of cocaine. Previous research has shown that trait impulsivity has been described as a common pathway to both sexual risk behavior and cocaine or alcohol abuse, while not to opiate abuse (6
). The findings of alcohol influence presents a special caution to alcohol-using substance users, for whom alcohol is not their primary substance of abuse and who may underestimate the risks of drinking.
Evidence of cocaine use in MM treatment was consistent with previous studies (8
). However, our findings of association (i.e. between cocaine diagnosis and having multiple sex partners and between cocaine use days and sex with drug or alcohol) are more limited than findings in the prior methadone maintenance literature (9
). This may be due to differences in sexual risk behavior outcomes (e.g. use of count of unprotected sexual occasions, dichotomous ratings of other sexual risk behaviors), or in their operational definitions (e.g. use of past 30 day timeframe). This may also be due to differences in drug and alcohol use measures. This study included clinical evaluation for abuse and dependence diagnoses, revealing associations not captured by frequency of use questions.
This study had the important advantage of including a large, multi-site sample of participants from community psychosocial outpatient treatment programs, as well as methadone maintenance programs. In doing so, it included the (arguably) higher risk sample of primary cocaine users – who are most likely to present to psychosocial outpatient treatment programs. At the same time, it differed from the majority of prior studies of cocaine users in characterizing a sample of cocaine users in treatment, and, perhaps, at greater readiness for HIV prevention intervention. However, this study was limited by its use of self-report assessment of substance use and sexual risk. Participants may have under-reported substance use if there were concerns about jeopardizing their treatment status, even with assurances of confidentiality.
This study demonstrated that women in psychosocial treatment and methadone maintenance treatment programs frequently engage in HIV sexual risk behavior. Among those in psychosocial treatment, cocaine, as well as alcohol use disorders, are prevalent, and have an association with increased HIV high risk sex behavior. HIV sexual risk prevention interventions are needed in psychosocial treatment and methadone maintenance programs that target the relationship between substance abuse and sexual risk behavior. Such intervention should target alcohol, as well as cocaine and opiate, use and problem use. Such intervention should address the impulsivity that drives both sexual risk behavior, especially among individuals engaging in cocaine and alcohol use and problem use.