Aids-Related Knowledge, Beliefs and Risk Behaviors in a Sample of Crack Addicts

• Published date: 01 July 1994
• Author: R. Lunn,M.R. Kowalewski,M.D. Anglin,K.A. Miller,M.E. Khalsa
• Date: 01 July 1994
• DOI: 10.1177/002204269402400313
• Subject Matter: Article

The Journal of Drug Issues 24(3),537-553 1994

AIDS-RELATED KNOWLEDGE, BELIEFS AND RISK

BEHAVIORS IN A SAMPLE OF CRACK ADDICTS

M.E. Khalsa

M.R. Kowalewski

R.

Lunn

M.D.

Anglin

K.A. Miller

This

longitudinal

study

examines

male

veterans

with

a

history

of

cocaine

dependence

and

treatment,

focusing

on the

relationship

between

levels

of

crack

use and

HIV-related

knowledge,

beliefs

and risk

behaviors.

Over

half the

subjects

were

African-American

and the

majority

were

heterosexual.

A

survey

instrument

was

administered

at one and two

years

after

initiating

treatment.

HIV

serotesting

was

conducted

at

each

interview

which

showed

the rate of

seropositivity

to be low at

both

points.

Knowledge

about

HIV

transmission

increased

significantly

overtimefor the

sample,

but no

differences

were

significantly

related

to

level

of

crack

use.

Few

subjects

report

the use

of

condoms

on a

consistent

basis,

regardless

of

crack

use

level.

However,

both

the

number

of

sex

partners

reported

and

beliefs

about

personal

susceptibility

to HIV

infection

increased

as the

level

of

crack

use

increased.

Our

crack-using

subjects

hadnotfully

internalized

their risk of HIV

infection

or

were

fatalistic

about

their

ability

to

change

HIV-related

risk

behaviors.

Either

of

these

possibilities

presents

a

significant

challenge

to

education

and

prevention

efforts

targeted

to

crack

users.

AIDS

education

efforts

in

drug

treatment

programs

may need to

more

strongly

emphasize

the

sexual

transmission

routes

of HIV

infection

and

highlight

the

effects

of

cocaine

useon

sexual

practices.

This

study examines a sample of men with histories of cocaine dependence

and treatment, focusing on the relationship between post-admission levels of crack

use and behaviors that could place these users (and their sexual partners) at risk

for contracting the human immunodeficiency virus (HIV). Previous research has

M.E. Khaba, M.D., Ph.D., is a principal

investigator

in the

UCLA

Drug

Abuse

Research

Center,

Neuropsychiatric Institute. School of

Medicine.

Mark R. Kowalewski, Ph.D.• is a postdoctoral

fellow

at the

UCLA Drug Abuse

Research

Center. His research has

focused

on

psychosocial

factors

involved

in Hlv-retated

behavioral changeamona cocaine abusersand

il\iection

drug users. Robert Lunn, Ph.D., was senior statistician at

the UCLA Drug Abuse

Research

Center.

Previous

to this he was a NIH

fellow

at UC

Berkeley.

He has 20 years

experience in multivariate analysis. M.D. Anglin, Ph.D., is director of the

UCLA

Drug Abuse

Research

Center

and Directorof the CaliforniaDrua

Abuse

Information

and

Monitoring

Project. His prior work

includes

studieson

the natural history of narcotic

addiction,

the

criminal

careers of

narcotic

offenders, variousaspectsof

methadone

maintenance

treatment, and the effectiveness of

treatment

for drug

abusing

populations.

Kristine A. Miller is a

research

associate

workingwith Dr.

Khalsa.

Directreprint

requests

and all

questions

to E.

Khalsa,

1100

Glendon

Avenue,

Suite763. Los

Angeles,

CA 90024.

©Journal of Drug Issues, Inc. 002-0426/94/03/537-553 $1,00

537

KHALSA, KOWALEWSKI, LUNN, ANGLIN, MILLER

recognized that injection of cocaine, like injection of heroin, places users at high

risk of transmission of HIV because of the potential for infection through sharing

contaminated injection equipment (Iguchi et al. 1990; Nemoto et al. 1990). For

example, in a study of injection drug users (IDUs) who applied for or were

enrolled in methadone treatment in San Francisco, Chaisson et al. (1989) found

that subjects who used cocaine by injection were at significantly increased risk for

HIV infection than those who injected only heroin. Increased frequency of

injection was also associated with increased risk of HIV infection among cocaine

users, but not among heroin users. Anthony et al. (1991) also found HIV

seropositivity rates higher among cocaine and heroin injectors when compared to

only heroin injectors.

On the other hand, non-injection cocaine users have typically been considered

to be less likely than IDUs to contract HIV. Des Jarlais and Friedman (1988)

suggested, for example, that smoking crack cocaine might be a "less risky" mode

of administration for HIV transmission than injection use of the drug because this

route eliminates the direct contamination path of needle sharing. However, a

substantial body of research has established that although non-injection use of

cocaine does remove the risk of transmitting HIV through contaminated injection

equipment, crack smokers (and other drug users) remain at risk of HIV infection

by other routes of transmission. Being under the influence of drugs or alcohol

during sexual encounters is related to engaging in sexual practices with high risk

for HIV transmission (Stall et al. 1986; Molgaard et al. 1988; Trocki and Leigh

1991). Crack use in particular may place users at high risk for sexual

transmission of HIV. For example, in a study of crack users who did not inject

drugs, IDUs who used crack, and non-crack-using IDUs in New Orleans, Ray et

al. (1990) found increased risk of HIV infection through sexual behaviors among

the crack smokers. Booth and Watters (1992) studied a sample similar to that

studied by Ray et aI., and found similar sexual risk levels among crack smokers in

Miami, Denver, and San Francisco. In a study of male and female arrestees in

Los Angeles, Longshore and Anglin (1991) noted that crack smoking males had

more sex partners and used condoms less frequently while intoxicated than

nonusers. Kowalewski et al. (1991) and Khalsa et al. (1992) also report

infrequent use of condoms among crack-smoking males in Los Angeles. Fullilove

et al. (1989) and Bowser et al. (1990) note a lower incidence of condom use and a

higher rate of sexually transmitted diseases (STDs) among crack smokers; in this

respect, STD rates provide an indication of sexual behaviors conferring high risk

for HIV transmission.

In addition to increased risk through infrequent condom lise, crack smokers

may be at higher risk for HIV transmission through blood-to-blood contact during

oral sex; the use of hot crack pipes may produce open sores on users' tongues and

lips (Williams et al. 1988). Furthermore, an ethnographic study of eight U.S.

cities (Ratner 1993) suggested that male crack smokers may also have penile

abrasions due to difficulties in achieving orgasm despite heightened interest in sex.

Penile abrasions might place users at higher risk during oral, vaginal and anal sex.

Economic motivations related to drug consumption may increase frequency of

sexual activities. In particular, research has generally indicated that many women

users engage in sex with multiple partners in order to obtain the drug or obtain

money to purchase the drug (Williams et al. 1988; Bowser 1989; Hasbrouk et al.

1990; Edlin et al. 1991; Boyle and Anglin 1993; Carlson and Siegal 1991; Tortu

et al. 1992). Reports of men exchanging sex for crack have been less frequent.

538 JOURNAL OF DRUG ISSUES