Men who have sex with men (MSM) experience greater mental health problems as compared with heterosexual populations. Informal social support plays a critical role in emotional well-being. The primary goal of this article is to examine the relationship between depressive symptoms and received social support from family, friends, and sex partners within the social network from a sample of 188 African American MSM in Baltimore, Maryland. We found that receiving emotional support from a family member or a sex partner was associated with reduced odds of having depressive symptoms. Receiving financial support from a family member or a friend was associated with increased odds of having depressive symptoms. The results suggest the importance of emotional support provided by family and sex partner in mental health and the potential value of training African American MSM in skills to enhance the quality of the relationships.
A large portion of violence associated with drug use is due to drug dealing. These analyses sought to examine injection drug users' attitudes and experiences of drug dealer violence.
The current study used the 18-month follow up data of STEP into Action (STEP) study, an HIV prevention intervention among drug injectors and their risk network members conducted in Baltimore, Maryland. Four scales assessed acceptability of drug dealer violence, willingness to talk to drug users about avoiding drug dealer violence, social norms about reporting drug dealer violence, and intentions to report drug dealer violence to the police.
Many (44%) of the 373 participants reported witnessing drug dealers' acts of violence within the prior 6 months. Although the majority of participants disagreed with statements on the acceptability of dealers using violence, only a minority indicated that they would call the police if they observed dealer violence. Most participants indicated that they would be interested in talking to drug users about how to avoid violent dealers. Males were more likely to report that violence was acceptable, whereas African Americans were less likely to condone violence. Those who were homeless and had higher incomes were more likely to report witnessing drug dealer violence.
These results suggest that it may be feasible to train current and former drug users and their risk network members in methods to promote violence reduction among drug dealers.
violence; drug dealer; injection drug users
The role of crack cocaine in accelerating the HIV epidemic among heterosexual populations has been well documented. Little is known about crack use as an HIV risk factor among African American men who have sex with men (AA MSM), a group disproportionately infected with HIV. We sought to compare the social and sexual network characteristics of crack-using and non-crack using AA MSM in Baltimore, MD, USA and to examine associations of crack use with sexual risk. Participants were recruited using street-based and internet-based outreach, printed advertisements, word of mouth. Inclusion criteria were being aged 18 years or older, African American or of black race/ethnicity, and have self-reported sex with another male in the prior 90 days. Crack use was operationalized as self-report of crack in the prior 90 days. Logistic regression was used to identify variables that were independently associated with crack use. Of 230 enrolled AA MSM, 37% (n = 84) reported crack use. The sexual networks of crack-using AA MSM were composed of a greater number of HIV-positive sex partners, exchange partners, and partners who were both sex and drug partners and fewer networks with whom they always use condoms as compared to non-crack using AA MSM. Crack use was independently associated with increased odds of bisexual identity and networks with a greater number of exchange partners, overlap of drug and sex partners, and lesser condom use. Results of this study highlight sexual network characteristics of crack-smoking AA MSM that may promote transmission of HIV. HIV interventions are needed that are tailored to address the social context of crack-smoking AA MSM risk behaviors.
African American men who have sex with men; Crack use; Social networks; HIV risk
Despite numerous behavioral interventions designed for women, rates of HIV and STIs are increasing. Interventions are needed that reach a large number of at-risk individuals. This study was a randomized clinical trial of a HIV/STI behavioral intervention conducted in Baltimore, MD, USA. Heterosexual women (n=169) completed a baseline and 3 semiannual follow-up visits. Participants were randomized into a standard of care comparison condition or a Peer Mentor condition. At the 6-month follow-up, Peer Mentors were less likely to have multiple sex partners [AOR: 0.28 (95% CI: 0.13, 0.63)]. At the 18 month follow-up assessment, Peer Mentors increased their condom use during vaginal [AOR: 0.47 (95% CI: 0.25, 0.87)] and anal sex [AOR: 0.24 (95% CI: 0.09, 0.68)] as well as with main [AOR: 0.41 (95% CI: 0.21, 0.77)] and non-main partners [AOR: 0.33 (95% CI: 0.14, 0.79]. Peer education is a sustainable approach to change risky sexual behaviors.
We compared social network characteristics of African American men who have sex with men only (MSMO) with social network characteristics of African American men who have sex with men and women (MSMW).
Study participants were 234 African American men who have sex with men who completed a baseline social network assessment for a pilot behavioral HIV prevention intervention in Baltimore, Maryland, from 2006 through 2009. We surveyed the men to elicit the characteristics of their social networks, and we used logistic regression models to assess differences in network characteristics.
MSMO were significantly more likely than were MSMW to be HIV-positive (52% vs 31%). We found no differences between MSMO and MSMW in the size of kin networks or emotional and material support networks. MSMW had denser sexual networks, reported more concurrent and exchange partners, used condoms with more sexual partners, and reported interaction with a larger number of sexual partners at least once a week.
Although there were many similarities in the social and sexual network characteristics of MSMO and MSMW, differences did exist. HIV prevention interventions should address the unique needs of African American MSMW.
This study examined correlates of disclosure of MSM behavior and seropositive HIV status to social network members among 187 African American MSM in Baltimore, MD. 49.7% of participants were HIV-positive, 64% of their social network members (excluding male sex partners) were aware of their MSM behavior, and 71.3% were aware of their HIV-positive status. Disclosure of MSM behavior to network members was more frequent among participants who were younger, had a higher level of education, and were HIV-positive. Attributes of the social network members associated with MSM disclosure included the network member being HIV-positive, providing emotional support, socializing with the participant, and not being a female sex partner. Participants who were younger were more likely to disclose their positive HIV status. Attributes of social network members associated with disclosure of positive serostatus included the network member being older, HIV-positive, providing emotional support, loaning money, and not being a male sex partner.
To assess the effectiveness of a peer-based, personal risk network focused HIV prevention intervention to 1) train IDUs to reduce injection and sex risk behaviors, 2) conduct outreach to behaviorally risky individuals in their personal social networks (called Risk Network Members), and 3) reduce RNM HIV risk behaviors.
Randomized controlled trial with prospective data collection at 6, 12, and 18 months. Intervention condition consisted of 5 group-sessions, one individual session and one session with Index and the RNM.
This study was conducted in Baltimore, Maryland from March of 2004 to March of 2006.
1) Index participants were aged ≥18 years and self-reported injection drug use in the prior 6 months and 2) their RNMs who were aged ≥18 years and drug users or sex partners of Index.
Outcomes included: 1) injection risk based on sharing needles, cookers and cotton for injection and drug splitting, 2) sex risk based on number of sex partners, condom use and exchanging sex and 3) Index HIV outreach behaviors.
A total of n=227 Index participants recruited n=366 RNMs. Retention of Index at 18-month follow-up exceeded 85%. Findings suggest the experimental condition was efficacious at 18-months in reducing Index participant injection risk (OR=0.38; 95%CI=0.18-0.77), drug splitting risk (OR=0.46; 95%CI=0.25-0.88), and sex risk among Index (OR=0.53; 95%CI=0.34-0.86). Significant intervention effect on increased condom use among female RNM was observed (OR=0.34; 95%CI=0.18-0.62).
Training active IDU to promote HIV prevention with behaviorally risky individuals in their networks is feasible, efficacious and sustainable.
HIV prevention intervention; social network; injection drug user; peer-oriented; randomized controlled trial
Despite decline in needle sharing in some countries, many injectors continue to share injection paraphernalia such as cookers and cotton. While individual and structural factors are associated with injection risk behavior, little attention has been given to the influence of social network members, such as norms, on injection paraphernalia sharing. The present study is a longitudinal analysis of the association between perceived norms and sharing syringes and non-syringe injection paraphernalia. Participants were enrolled in the STEP into Action study and reported injection drug use at both baseline and follow-up assessments (n = 398). Results showed that descriptive norms, or believing that peers practiced risky injection behaviors, predicted sharing both syringes and nonsyringe paraphernalia. However, there was no association between injunctive norms (i.e., perceived peer approval) and either syringe or non-syringe paraphernalia sharing. Changing norms may lead to sustained behavior change. Accessible, norms-based interventions are needed to discourage drug injectors from sharing injection paraphernalia.
HIV; Injection drug use; Norms; Drug paraphernalia
Adopting socioecological, intersectionality, and lifecourse theoretical frameworks may enhance our understanding of the production of syndemic adverse health outcomes among gay, bisexual and other men who have sex with men (MSM). From this perspective, we present preliminary data from three related studies that suggest ways in which social contexts may influence the health of MSM. The first study, using cross-sectional data, looked at migration of MSM to the gay resort area of South Florida, and found that amount of time lived in the area was associated with risk behaviors and HIV infection. The second study, using qualitative interviews, observed complex interactions between neighborhood-level social environments and individual-level racial and sexual identity among MSM in New York City. The third study, using egocentric network analysis with a sample of African American MSM in Baltimore, found that sexual partners were more likely to be found through face-to-face means than the Internet. They also observed that those who co-resided with a sex partner had larger networks of people to depend on for social and financial support, but had the same size sexual networks as those who did not live with a partner. Overall, these findings suggest the need for further investigation into the role of macro-level social forces on the emotional, behavioral, and physical health of urban MSM.
Homosexuality; Male; Urban health; Social environment
The purpose of this study was to examine the association between social network characteristics and peer norms related to sharing needles and shooting gallery use. Multivariate logistic regression modeling was used to identify factors that were independently associated with shooting gallery use among a sample of injection drug users recruited in Baltimore, Maryland. Of 842 study participants, 35% reported attending a shooting gallery in the past 6 months. Social networks of shooting gallery users were larger, had a greater number of injectors and crack smokers, were younger and less dense with fewer kin members compared to networks of non-gallery attenders. A greater proportion of those who used a gallery perceived that their peers shared needles and that peers would not disapprove if they used a dirty needle. Future research is needed to understand how social networks and peer norms are specific to behavioral settings and how this may impede adoption of preventive behaviors.
shooting gallery; social network; peer norms; injection drug user; HIV
We examined the association of individual demographic and behavioral attributes, partnership (dyad) and social network characteristics with unprotected sex in the heterosexual dyads of IDUs in St Petersburg, Russia. Of the individual-level characteristics female gender and younger age; and of the dyad-level characteristics sharing injecting equipment, social exposure to the sex partner (“hanging out with” or seeing each other daily), and both partners self-reporting being HIV infected were associated with unprotected sex. Although self-reported HIV discordant couples were less likely to engage in unprotected sex, it was reported in over half of self-reported HIV discordant relationships. This study highlights the intertwining of sexual risk and injecting risk, and the importance of sero-sorting based on perceived HIV status among IDU sexual partnerships in St Petersburg, Russia. A combination of social network and dyad interventions may be appropriate for this population of IDUs, especially for IDUs who are both injecting and sex partners, supported by free and confidential rapid HIV testing and counseling services to provide a comprehensive response to the wide-spread HIV epidemic among IDUs in St Petersburg.
Injecting drug users; Risk networks; Sexual risk; HIV infection risk; Dyad analysis; Russia
In this study, we investigated how individual attributes, dyad characteristics and social network characteristics may influence engaging in receptive syringe sharing, distributive syringe sharing and sharing cookers in injecting partnerships of IDUs in St Petersburg, Russia. We found that all three levels were associated with injecting equipment sharing, and that dyad characteristics were modified by characteristics of the social network. Self-reported HIV discordance and male gender concordance played a role in the risk of equipment sharing. Dyad interventions may not be sufficient to reduce injecting risk in IDU partnerships, but a combination of dyad and network interventions that target both IDU partnerships and the entire IDU population may be more appropriate to address injecting risk among IDUs.
Injecting drug users; Risk networks; Injecting risk; Dyad analysis; Russia
Using a social network approach to recruitment, we analyzed the factors that predicted recruitment of an HIV seropositive network member by active injection drug users (IDUs). IDUs were asked to bring in drug and sex network members, whom they delineated on a social network inventory. The 297 index participants recruited 425 networks, of whom 17.3% were seropositive. The majority of seropositive members were recruited by IDUs who reported no seropositive risk network members. The strongest predictor of recruiting seropositives was ethnicity, with African American indexes more than 3 times more likely than others to recruit seropositives. Those African American indexes who reported that they had no seropositive network members were over 10 times more likely to recruit a seropositive. These results suggest the feasibility to target active drug users to recruit seropositives and emphasize the public health importance of focusing network approaches on the networks of African American IDUs.
HIV; Social Network; HIV testing; injection drug use; recruitment; seropositives
To assess the attitudes of HIV seropositive current or former drug users towards HIV partner counseling and referral services (PCRS) and to determine if opinion varies by partner type.
We used a cross-sectional survey using structured and semi-structured questions to measure attitudes towards PCRS.
The majority of the sample was African-American (97%), male (63%) and had been diagnosed with HIV for a mean of 7.9 years. Most agreed that PCRS would help stop the spread of HIV and AIDS (87%). A range of reactions to scenarios of their drug and sex partners being informed were observed and included positive reactions (e.g. PCRS as a means to facilitate testing of their partners and early treatment) to negative (e.g. feelings about guilt, shame and concern about partner responses).
Data from this study indicate that HIV positive drug users view PCRS as a viable practice for preventing the spread of HIV, though barriers exist to engaging clients to identify partners.
The range of reactions noted in this study underscore the importance of providing flexible options for PCRS based on partner type. Additional training for counselors, time for case-management and meetings with sex and drug partners and fieldwork for locating contacts are important considerations for providers.
Partner notification; PCRS; HIV testing; drug users
To assess among injecting drug users (IDUs) in St Petersburg, Russia, the urban environmental, social norms, and individual correlates of unsafe injecting.
Between December 2004 and January 2007 IDUs (N=446) were interviewed in St. Petersburg, Russia.
Prevalence of HCV was 96% and HIV 44%; 17% reported receptive syringe sharing after an HIV infected IDU (RSS); 49% distributive syringe sharing (DSS); 76% sharing cookers, 73% sharing filters and 71% syringe mediated drug sharing (SMS) when not all syringes were new. Urban environmental characteristics correlated with sharing cookers and SMS; and social norms correlated with RSS, DSS and sharing cookers. Individual correlates included cleaning used syringes (all five dependent variables) and self-report of HIV infection (RSS and DSS).
HIV status disclosure is an unreliable but frequently used HIV prevention method among IDUs in St. Petersburg, who reported alarmingly high levels of injecting equipment sharing. Voluntary counseling and testing should be widely available for this population. Ethnography is needed to assess the effectiveness of the syringe cleaning process. Prevention interventions need to be ongoing among IDUs in St. Petersburg, and should incorporate urban environmental factors and social norms, which may involve peer education and social network interventions.
Russia; Injecting drug users; Injecting equipment sharing; HIV infection; Hepatitis infections
The purpose of this study was to compare the social network characteristics of men who have sex with men (MSM) to non-MSM (NMSM) in a sample of predominately African American drug users. Specifically, we were interested in examining the differences in structure of the networks and drug and sexual risk partners within the network.
Data came from 481 male participants who reported having >=1 sex partner in the past 90 days. MSM was defined as having sex with a male. Data on social network composition were collected using a Social Network Inventory.
Of 481 men, 7% (n=32) were categorized as MSM. Nearly two-thirds of MSM did not identify as gay. MSM were more likely to be HIV positive as compared to men who did not have sex with men. Social networks of MSM were younger and a greater proportion were HIV positive. After adjusting for HIV status, networks of MSM were less dense, indicating fewer connections among network members. Among injection drug using men in the sample, MSM reported a greater number of needle sharing networks than NMSM.
These findings underscore the importance of including social network factors in investigations of HIV risk among MSM. Further studies should focus on dynamics within a network and how they may operate to affect behavior and health.
MSM; social networks; HIV
Few studies have examined sexual risk behaviors of HIV-positive, heterosexual, injection drug using (IDU) men. We investigated such behaviors and associations with risk among sexually active, HIV-positive IDU men who reported only female sex partners in the 3 months prior to baseline interview. We examined associations separately for four non-exclusive groups of men by crossing partner type (main or casual) and partner serostatus (HIV-positive or HIV-negative/unknown). Of 732 male participants, 469 (64%) were sexually active with only female partners. Of these 469 men, 155 (33%) reported sex with HIV-positive main partners, 127 (27%) with HIV-negative or unknown serostatus main partners, 145 (31%) with HIV-positive casual partners, and 192 (41%) with HIV-negative/unknown serostatus casual partners. Significant multivariate associations for unprotected sex with HIV-negative or unknown serostatus main partners were less self-efficacy to use condoms, weaker partner norms supporting condoms, and more negative condom beliefs. Similar correlates were found for unprotected sex with HIV-positive main and casual partners. In addition, alcohol or drug use during sex was a significant correlate of unprotected sex with HIV-positive main partners, while depression was significant for HIV-positive casual partners. For unprotected sex with HIV-negative/unknown status casual partners, self-efficacy for condom use, sex trade, and education were significant multivariate correlates. A combination of broad and tailored intervention strategies based on the relationship pattern of men's lives may provide the most benefit for reducing unprotected sex with female partners.
Heterosexual men; HIV-positive; Injection drug users; Sexual risk
Training and distributing naloxone to drug users is a promising method for reducing deaths associated with heroin overdose. Emergency Medical Service (EMS) providers have experience responding to overdose, administering naloxone, and performing clinical management of the patient. Little is known about the attitudes of EMS providers toward training drug users to use naloxone. We conducted an anonymous survey of 327 EMS providers to assess their attitudes toward a pilot naloxone program. Of 176 who completed the survey, the majority were male (79%) and Caucasian (75%). The average number of years working as an EMS provider was 7 (SD=6). Overall attitudes toward training drug users to administer naloxone were negative with 56% responding that this training would not be effective in reducing overdose deaths. Differences in attitudes did not vary by gender, level of training, or age. Providers with greater number of years working in EMS were more likely to view naloxone trainings as effective in reducing overdose death. Provider concerns included drug users’ inability to properly administer the drug, program condoning and promoting drug use, and unsafe disposal of used needles. Incorporating information about substance abuse and harm reduction approaches in continuing education classes may improve the attitudes of provider toward naloxone training programs.
Drug users; EMS providers; Naloxone; Overdose prevention
Nonfatal drug overdoses are common among heroin users. While several factors that increase risk of overdose have been identified, there is little research on the role of mental health status. The purpose of this study was to examine the association between depressive symptoms and history of overdose. A sample of 729 opiate and cocaine users completed a cross-sectional survey. Of the sample, 65% reported never having overdosed, 31% had overdosed longer than 12 months before the interview, and 4% had overdosed within the past 12 months. Results indicate that a high score on the Center for Epidemiological Studies Depression Scale (CES-D), a measure of depressive symptoms, was associated with having overdosed within the past 12 months (relative risk ratio [RRR]=3.06; 95% confidence interval [CI], 1.33 to 7.05) after adjusting for age, gender, injection frequency, and physical health impairment. These results suggest that drug users with depressive symptoms should be targeted for overdose prevention programs.
Cocaine; Depression; Heroin; Injection drug users; Overdose