Reducing Sexual Risk Among Injection Drug Users

Multiple sexual partnerships, sex work, and unprotected intercourse are common among injection drug users (IDUs). IDUs are also more likely to engage in heterosexual anal intercourse, which is associated with greater risk for HIV transmission than is vaginal sex. Thus, reducing IDUs' sexual risk is an important step in stemming the HIV epidemic.

• A research team including staff from RAND Health examined sexual risk behavior among nearly 1,500 male and female IDUs recruited from syringe-exchange programs in California. The team examined three kinds of sexual risk behavior—unprotected anal/vaginal intercourse, multiple recent sexual partnerships that included steady partners, and anal intercourse between male and female IDUs—and linked these behaviors to a wide range of factors, including sociodemographic characteristics, HIV status, injection behavior, and use of different types of drugs.
• A majority of these IDUs was sexually active, had multiple sexual partners, and did not use condoms consistently for anal, vaginal, or oral sex. Women, in particular, were likely to engage in sex work, and about one-fifth reported substantial levels of anal intercourse.
• Heterosexual anal sex was linked to a generally risky lifestyle that included a history of sexually transmitted diseases, multiple sexual partnerships, syringe sharing, and amphetamine use. These findings highlight the need to explicitly address heterosexual anal sex in HIV-prevention activities.
• Both men and women who had steady partners were less likely to use condoms consistently, perhaps because they associated condom use with lack of intimacy. Programs are needed to destigmatize condom use with couples.
• IDUs tended to engage in selective risk taking—e.g., limiting syringe sharing to their personal networks and not using condoms with their steady partners. Such strategies work only if both partners have been tested for HIV and remain monogamous, and if their injection networks are free of infection and closed to outsiders. However, in this group of IDUs, women with a history of sexually transmitted diseases were twice as likely to have both a steady partner and multiple partners.
• Programs designed to increase condom use in steady partnerships could substantially reduce sexual risk among IDUs.