HIV infection continues to disproportionately impact minorities in the United States.1
In a recent report, the incidence of HIV infection was estimated to be 7 times higher among African-Americans and 3 times higher in Hispanics than among Whites. African-Americans comprise 47% of persons living with HIV, followed by Whites (34%) and Hispanics (17%). While the most prevalent mode of transmission for persons living with HIV infection continues to be male-to-male sexual contact (MSM; 45%), high-risk heterosexual contact (27%) and injection drug use (22%) also contribute significantly to transmission. Furthermore, studies have found comparable HIV infection rates between injection and non-injection drug users.2-4
Non-injection drug use (non-IDU) contributes to the increased likelihood of engaging high-risk heterosexual contact, such as unprotected intercourse and sex trading5,6
and bridging between injection drug use (IDU) and non-IDU social and sexual networks4
, highlighting the importance of directing HIV prevention efforts toward drug users and drug treatment programs. Racial/ethnic differences in transmission routes further highlight the need to understand the complex interaction between race/ethnicity, drug use, and HIV risk behaviors. For example, in comparison to White men (14%), the route of transmission is more likely to be IDU-related or heterosexual sex for African American (35.7%) and Hispanic (26.6%) men infected with HIV.7
Conversely, the route of HIV transmission is less likely to be heterosexual sex among White women (74.8%) in comparison to African American (86.7%) and Hispanic (83.5%) women.
The effectiveness of HIV risk reduction interventions may differ for racial/ethnic minority samples based on the intervention strategy employed. A comprehensive meta-analysis spanning 17 years and various intervention settings, target samples, and countries found that, while certain strategies were equally effective across racial/ethnic groups, persons of African backgrounds tended to benefit more from programs utilizing behavioral skills components, self-management skills training, and HIV-counseling and testing; while condom provision was more effective in White samples.8
Recent reviews of HIV risk reduction interventions specifically focused on drug users and drug treatment programs suggest outcomes are somewhat mixed. A meta-analysis of interventions conducted in drug treatment programs found treatment effect sizes were lower and interventions less comprehensive in programs where participants were predominantly minorities.9
In contrast a meta-analysis of HIV risk reduction interventions targeting injection drug users found no racial/ethnic differences in impact on sexual risk behaviors; however minority participants were more likely than Whites to decrease IDU behaviors following HIV risk reduction interventions.10
Furthermore, a recent CDC survey of injection drug users found participation in behavioral interventions to be higher for African-Americans and Hispanics than Whites.11
Given the high incidence of HIV in minorities and evidence suggesting possible differential effectiveness of HIV risk reduction intervention strategies for minorities, studies examining ethnic differences in the prevalence and correlates of risk behaviors to inform program development are warranted. To date, this literature has been limited in a number of ways. Many studies in this area are more narrowly focused restricting samples to a single racial/ethnic group (e.g., within African-Americans) or within gender (e.g. African-American vs. White females). In addition, the racial/ethnic distribution in many studies is often too small to conduct valid comparisons and is often controlled for in the analyses.
At the same time, an extensive body of research has identified multiple risk factors for HIV risk behaviors in general, such as stimulant use,5,12-16
homelessness or unstable housing,17-20
psychological distress or co-occurring mental illness,19,21-24
and recent incarceration,28
with mixed findings for alcohol use.16,29-35
However investigators rarely examine whether these relationships vary with racial/ethnici group. For example, one study examined differences between Whites, African-Americans and Hispanics in psychosocial risk factors; however, whether these risk factors differentially impacted the likelihood of engaging in sexual risk behaviors was not examined.36
Similarly, in a study of new drug users, African-American race, homelessness, childhood neglect, paranoia, and interpersonal conflict style predicted frequency of engaging in high risk sexual behavior; however the interaction between racial/ethnic group and individual risk factors was not examined.37
Other studies have examined the relationship between risk factors and HIV risk behaviors within racial/ethnic group. A relationship between alcohol use, crack use and combined alcohol and crack use and high risk sexual activities was found in an African-American only sample of non-injection drug users.38
Lower education, crack use, and high risk sexual partners predicted HIV infection in rural African-Americans.39
Alcohol use was related to both injection and sexual risk behaviors in a sample of injection drug users in Puerto Rico.31
Because of the relationship between drug use and HIV high risk sexual behaviors, as well as evidence that HIV risk factors and risk behaviors vary between racial/ethnic groups, it is important to better understand these differences within the context of drug abuse treatment programs. Drug abuse treatment programs provide an important treatment system portal in which HIV prevention interventions might effectively target individuals at high risk for HIV infection and transmission. The purpose of the present study was to examine racial/ethnic differences in the prevalence and correlates of sexual and drug-related HIV risk behaviors in a large sample of treatment-seeking individuals with substance use disorders participating in seven multi-site trials of the National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN). The CTN offers a unique opportunity to study racial/ethnic-related HIV transmission risk behaviors of persons entering substance abuse treatment.40,41
By pooling data across trials, a large, demographically and geographically diverse treatment sample can be obtained. In addition, combining data across CTN trials allows us to systematically examine multiple HIV risk factors with a sufficient sample size to examine racial/ethnic differences. The design of this study parallels an earlier secondary data analysis of five CTN trials examining gender differences in the prevalence and correlates of HIV risk behaviors.42
The specific aims of this study were to: (1) compare HIV risk behaviors among non-Hispanic Blacks, Hispanics, and non-Hispanic Whites in this large, geographically and demographically diverse sample of drug users, and (2) test whether the relationship between multiple HIV risk factors and HIV risk behaviors varies by racial/ethnic group. Specifically, this study examined whether race/ethnicity moderates the relationship of stimulant use, alcohol use, psychiatric symptoms, physical and sexual abuse history, family/social relations, housing stability, drug use severity, and legal involvement with HIV risk behaviors.
Well-documented economic and health care disparities for African-Americans coupled with the unique characteristics of their sexual network patterns39
may make African-Americans particularly vulnerable to engaging in high risk behaviors. A similar constellation of economic and health care disparities as well as migration patterns and cultural factors also impact HIV transmission among Hispanics.43,44
Accordingly, we hypothesized that the multiple HIV risk factors described above would be associated with engaging in greater HIV risk behaviors for African-Americans and Hispanics than Whites.