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Association between drug use patterns and HIV risks among homeless, runaway, and street youth in Northern California
Drug and Alcohol Dependence 51 (1998) 219 – 227
Association between drug use patterns and HIV risks among homeless, runaway, and street youth in Northern California Alice A. Gleghorn *, Rani Marx, Eric Vittinghoff, Mitchell H. Katz San Francisco Department of Public Health, AIDS Office, 25 Van Ness A6enue, Suite 500, San Francisco, CA 94102 -6033, USA Received 27 August 1997; accepted 8 February 1998
Abstract We examined relationships between drug use patterns and HIV risk behaviors among 1121 street-recruited homeless, runaway, and ‘street youth’ in Northern California. Comparisons demonstrated that youth using any heroin, methamphetamine, or cocaine exhibited more sexual risks than non-users, while primary stimulant and combined heroin/stimulant users showed greatest sexual risk. Combined heroin/stimulant injectors showed higher risk injection practices than primary heroin or primary stimulant injectors, including frequent injections and backloading syringes. Interventions for street youth should be tailored to current drug use patterns since those using combinations of heroin and stimulants may require more comprehensive prevention, support and treatment services. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Homeless; Street youth; Human immunodeficiency virus; Drug use patterns; Prevention; Injection drug use
1. Introduction Homeless, runaway, and ‘street’ youth (youth involved in the illegal street economies of drugs, prostitution, theft, or panhandling) are at risk for HIV infection through both sexual and drug-related behaviors (Rotheram-Borus et al., 1991). Previous studies of these youth (hereafter referred to as ‘street’ youth) have found high rates of drug use (MacKellar et al., 1996; Kral et al., 1997; Kipke et al., in press), and a majority (79%) of these youth acknowledge a history of using drugs associated with high fatality risk and high dependency potential such as methamphetamine (speed), cocaine, heroin and alcohol (Kipke et al., 1995). Up to 43% of street youth report ever injecting drugs (Kral et al., 1997), 43% report a history of trading sex for food, money, drugs or shelter (Kipke et al., 1995), a majority (median prevalence 58%) have recent episodes of unprotected sex (MacKellar et al., 1996), and 75% report ever having sex while under the influence of drugs or * Corresponding author. Tel.: +1 415 2553722.
alcohol (Kral et al., 1997). Among street youth who inject drugs, rates of sharing needles and syringes range from 59% (Kipke et al., 1995) to 62% (Kral et al., 1997). HIV seroprevalence is also high among street youth tested in clinics, ranging from 5.3% (Stricof et al., 1991) to 8.2% (Shalwitz et al., 1990). Since different drugs have different physiological effects, use of a particular drug or combinations of drugs may correspond to different patterns of use, dependence, associated risk behaviors, and response to treatment (Klee, 1993; Darke et al., 1994; Cunningham et al., 1996). Several studies of drug use patterns in adult populations of injection drug users (IDUs) and gay/bisexual men have suggested a link between use of cocaine (Cohen et al., 1994; Bux et al., 1995; Hudgins et al., 1995; Joe and Simpson, 1995; Longshore and Anglin, 1995; Camacho et al., 1996), methamphetamine (Harris et al., 1993; Klee, 1993; Crofts et al., 1994; Ka¨ll, 1994; Stone et al., 1995), heroin (Gossop et al., 1993; Klee, 1993; Baker et al., 1994; Ross et al., 1994; Bux et al., 1995), or speedball (use of heroin and cocaine together) (Titus et al., 1994; Camacho et al., 1996;
0376-8716/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S0376-8716(98)00042-8
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Brackbill et al., 1997) and HIV risk behaviors or HIV serostatus. Few studies have evaluated patterns of drug use among youth. Gorman (1996) noted that speed use (both injection and non-injection use) is especially popular among younger gay and bisexual men. Garfein et al. (1996) studied IDUs between the ages of 18 and 25, and found that a history of injecting cocaine was associated with HIV infection, as well as with other high risk sexual and drug use behaviors. In a study of street youth (Kipke et al., 1995), evaluated drugs with high fatality risk as a class and noted a relationship between use of these ‘high risk’ drugs (Gable, 1993) and a history of sexually transmitted disease, survival sex (trading sex for food, money, drugs or shelter), multiple sex partners, and being ‘high’ on drugs or alcohol during last sexual intercourse. However, that study did not differentiate between use of specific drugs and risk behaviors. To our knowledge, the relationship between HIV risk behaviors and specific drug use patterns among street youth has not been evaluated. To address these issues, the current study reports on patterns of drug use among a street-recruited population of homeless, runaway and street youth, and the relationship of these patterns to sexual and injection-related risk behaviors.
2. Method
2.1. Recruitment Subjects for this study were recruited as part of the Centers for Disease Control and Prevention (CDC) funded AIDS Evaluation of Street Outreach Project, or AESOP. AESOP targeted the risk behaviors of high risk populations of street youth and IDUs in eight metropolitan areas with a variety of outreach strategies. Specific details are provided elsewhere for the overall project (Anderson et al., 1996), for the Northern California site (Clements et al., 1997) and for the San Francisco intervention (Gleghorn et al., 1997). Data for Northern California were collected in separate intervention (San Francisco) and comparison sites (Berkeley, Santa Cruz and Arcata). The four recruitment cities were selected through preliminary ethnographic research for having similar populations of street youth who congregate in public locations, such as parks and street corners. The survey was conducted in a series of sequential cross-sectional data collection periods. Following an initial assessment conducted from January 1993 to August 1993, four additional survey periods roughly 3.5 months long were conducted with a break of approximately 2 months between survey periods ending in October, 1995. A total 1795 youth were approached for
interviews. There was a 17% refusal rate, and a 72% eligibility rate. Of the youth eligible for the study, 93% completed an interview. Deleting duplicates, a total of 1121 interviews were included in this analysis. Since preliminary analysis determined that implementation of the AESOP intervention in San Francisco was not associated with changes in drug use, the current analysis combines data across all waves from the four recruitment sites. Youth were recruited for this study using the streetbased sampling methods described in Clatts et al. (1995), Anderson et al. (1996) and Clements et al. (1997). This sampling strategy was designed to assure that youth sampled from a given location were representative of all youth present during a given sampling period. In each city, potential recruitment locations were identified and monitored for youth activity during preliminary research. Locations with adequate numbers of youth were selected as subject recruitment sites. The number of interviews to be obtained from each site was calculated from the pilot observations to correspond to the expected available samples. To recruit subjects for the study, interviewers visually assessed each recruitment site for the presence of target youth, counted the available youth and approached every second youth who appeared to meet the age criteria for screening. Eligibility was determined through a brief discussion with the youth. Eligibility criteria included youth between the ages of 12 and 23 years old who were: (1) currently homeless (for at least 2 months), and/or (2) who had experienced repeated periods of homelessness over the past 12 months, and/ or (3) who were engaged in the street economy (prostitution, drug sales, theft, panhandling, pornography or selling stolen property).
2.2. Procedures Interviewers briefly described the study to eligible youth, acquired verbal consent from interested participants, and accompanied the youth to a semi-private location where the interview was conducted. Youth received a $20 remuneration for their participation in the 30–40-min interview. In addition, the interviewer purchased a small meal (up to $5 value) for the youth’s consumption during the interview. The study design, questionnaire and consent procedures were reviewed and approved by the Institutional Review Board of the University of California, San Francisco.
2.3. Measures The survey instrument was developed by the CDC for use at all AESOP sites. The questionnaire assessed demographic characteristics including gender, age, ethnicity, and current homelessness. Sexual behaviors were
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also assessed, including sexual orientation, recent sexual activity with main or casual partners, and sexual risk behaviors (i.e. recent casual sex partner, more than one sex partner in the past month, anal sex during the past month, use of any drug (including alcohol) during last vaginal sex with main or casual partner, no condom use during last sex with a main or casual partner, and a history of trading sex for money, food, drugs or shelter). History of drug use and drug use within the last 30 days were assessed for the following substances: cocaine, heroin, speed, speedball, crack, ecstasy, nitrous oxide, LSD and hallucinogens other than LSD (mushrooms, peyote, or mescaline). Injection during the last 30 days was assessed for heroin, speed, speedball, cocaine, ecstasy, and LSD. Variables related to injection history included history of injecting any drug, and age at first injection of any drug. Injection-related HIV risk practices assessed were: total number of injections of any drug during the past 30 days, any sharing of syringes in the past 30 days, no use of bleach at last injection, use of a non-sterile syringe at last injection, and history of backloading syringes (i.e. the use of one syringe to fill another with drugs), sharing cookers, having others prepare and administer injections, or injecting without cleaning the injection site. In defining categories of recent drug use, we focused on differentiating patterns of recent speed, cocaine (including crack) and heroin use. Category determination was made based on reported use during the past month (through snorting, swallowing, smoking, or injecting) of heroin, speed, and cocaine. Categorization was guided by field observations of youth drug use behaviors, drug use history, and overlap between recent use of speed, cocaine, and heroin. According to outreach worker observations, patterns of speed and cocaine use among these youth are fluid, subject to drug availability and street price, with cocaine typically being less accessible. Therefore, for the majority of analyses, recent use of cocaine and/or speed was analyzed as a primary stimulant category. In examining differences in the sexual risk behaviors of subcategories of stimulant users (primary cocaine, primary speed, and combined speed and cocaine), only exploratory analyses were conducted due to small cell sizes. In addition, a distinct subgroup of youth tends to use whatever drug is most readily available, resulting in the use of combinations of drugs during a 30-day period. Therefore, youth were divided into four mutually exclusive categories of drug use: use of heroin and stimulants (combined heroin/stimulant category); use of heroin without use of stimulants (primary heroin category); use of stimulants without heroin (primary stimulant category); and no use of heroin, or stimulants (no heroin, or stimulants category).
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2.4. Analysis Chi-square analyses were conducted to detect differences between demographic characteristics, sexual variables, and injection risk activities by recent drug use categories. To evaluate the relationship between HIV sexual risk behaviors by current drug use patterns, bivariate odds ratios were calculated. The KruskalWallis test was conducted to evaluate differences in number of injections during the past month and age of first injection between injection categories.
3. Results
3.1. Demographic characteristics and sexual acti6ity The sample was predominately heterosexual (78%), white (86%), and currently homeless (84%) (Table 1). Nearly two-thirds (62%) were over 18 years of age, and 64% were male (results not shown). Almost two-thirds of the youth (63%) reported vaginal intercourse during the past 30 days; of these sexually active youth, vaginal sex with a main partner only was reported by 48% of the sample, sex with only casual partners was reported by 45%, and sex with both types of partners in the past month was reported by 7%. Few youth (4%) engaged in anal sex in the past month.
3.2. Drug use history and recent use Virtually all youth (99.9%) reported lifetime use of some drug (Table 2). The most common drugs that youth reported ever using were: LSD, marijuana, hallucinogens other than LSD, alcohol, nitrous oxide, cocaine, heroin, speed, and speedball. Thirty-nine percent of the sample reported ever injecting drugs. Nearly all youth (95%) reported drug use within the past month (Table 2). Marijuana, alcohol, and LSD were the most frequently used drugs. One-fifth (21%) of the youth had injected any drugs during the past 30 days; the most commonly injected drugs were heroin, speed, speedball, and cocaine. One-fifth of the sample were primary stimulant users; subcategories of these youth (results not shown) included few (3%, n= 39) who used cocaine or crack alone in the past month, slightly more (5%, n = 51) who reported use of both cocaine and speed, and a greater proportion (13%, n= 141) who reported use of speed but not cocaine.
3.3. Comparisons of demographic characteristics and sexual risks between recent drug use categories There were no gender or age differences by current drug use (results not shown). Whites were significantly
48 (9)
(85) (78) (18) (57) (24) (16) (29)
149 (13)
446 409 93 299 127 82 56 85 (67)
(86) (84) (22) (63) (33) (21) (40)
248 (68)
964 936 248 710 371 239 156
No heroin or stimulant Use (n =527) n (%)
b
Within the past month. Of those who had sex with a main partner in the past month (n =392). c Of those who had sex with a casual partner in the past month (n = 371). d n missing= 1. e n missing=3. f n missing= 4.
a
White Currently homeless Gay/lesbian/bisexual orientationd Vaginal sex with any partnera Casual sex partnera \1 sex partnera Use of drugs/alcohol at last intercourse, main partnerb,e Use of drugs/alcohol at last intercourse, casual partnerc,f History of trading sex for money, food, drugs, or sheltere
Total sample (n= 1121) n (%) (82) (85) (27) (66) (42) (27) (45)
37 (16)
54 (56)
189 196 63 153 96 62 30
Primary stimulant use (n =231) n (%)
17 (14)
22 (58)
114 (93) 105(85) 31 (25) 80 (65) 38 (31) 22 (18) 21 (47)
Primary heroin use (n =124) n (%)
Table 1 Demographic characteristics and sexual risk behaviors by current drug usea among street youth in Northern California
(90) (95) (26) (75) (46) (31) (59)
47 (20)
87 (82)
215 226 61 178 110 73 49
Combined heroin/stimulant use (n= 239) n (%)
0.001
0.001
0.01 0.001 0.008 0.001 0.001 0.001 0.001
Chi-square, P value
222 A.A. Gleghorn et al. / Drug and Alcohol Dependence 51 (1998) 219–227
A.A. Gleghorn et al. / Drug and Alcohol Dependence 51 (1998) 219–227
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Table 2 Lifetime, current use and current injection drug use among street youth in Northern California Drug (n =1121)
Ever used n (%)
Current usea n (%)
Use of any drugc Use of any injected drugd LSDe Peyote/mescaline/mushrooms Nitrous oxidee Speedd Heroin Cocainef Crackf Speedball Ecstasy Alcohol Marijuana
1120 435 1080 1023 917 854 834 834 557 807 612 938 1028
1062 234 555 327 246 377 354 161 136 84 165 597 847
(99.9) (39.0) (96.6) (91.3) (82.0) (76.5) (74.4) (74.7) (49.9) (72.3) (54.8) (83.7) (91.7)
(94.7) (21.0) (49.5) (29.2) (21.9) (33.6) (31.6) (14.4) (12.1) (7.5) (14.7) (53.3) (75.6)
Current injectionb n (%)
6 (2.6)
135 (57.7) 183 (78.2) 60 (25.6) 63 (26.9) 14 (6.0)
a
Within the past month. Among injection drug users during the past month. c Including alcohol and marijuana. d n missing =5. e n missing =3. f n missing = 4. b
more likely to report primary heroin use than nonwhites (Table 1). Current homelessness and sexual orientation also differed by drug use categories: combined heroin/stimulant users were nearly all homeless; and primary stimulant users, combined heroin/stimulant users, and primary heroin users more often reported gay/lesbian/bisexual sexual orientation. There were no significant differences with respect to condom use at last sex with any partner, or recent anal sex (results not shown). However, there were significant differences in the following sexual risk behaviors for recent drug use categories: combined heroin/stimulant users were more likely to have a casual sex partner, have more than one sex partner in the past month, use drugs at last intercourse with a main or casual partner, or ever trade sex compared to other drug users (Table 1). We compared sexual risk behaviors which were significant in chi-square analyses between users and nonusers of heroin and stimulants (Table 3). Combined heroin/stimulant users and primary stimulant users had significantly more sexual risk behaviors than nonusers. In our exploratory analysis, primary cocaine users showed elevated risks related to casual sex partners (results not shown), including having a recent casual sex partner (54%), having more than one recent sex partner (33%), and using drugs during last sex with a casual sex partner (81%). A majority of primary cocaine (82%) and combined speed and cocaine users (85%) did not use condoms during last intercourse with a main partner, while combined speed and cocaine users showed the highest percentage of using drugs at last sex with a main partner (69%). During their most recent sexual encounter with a casual partner, primary
speed users were least likely to use drugs (49%), but were the most likely to have unprotected sex with a casual partner (60%).
3.4. Injection acti6ities Table 4 presents injection risk activities by injection drug use category. Comparisons of injection behaviors between combined heroin/stimulant IDUs and other injection drug categories revealed several contrasts. Age at first injection of any drug and ever using one syringe to load another (backloading) differed significantly across injection drug use categories: combined heroin/ stimulant injectors initiated injection at the youngest age and were more likely to backload than other drug users. The number of injections in the last 30 days also differed significantly across drug use categories: primary stimulant injectors reported the lowest number of injections per month, while combined heroin/stimulant injectors reported the highest.
4. Discussion This study expands findings of previous work by relating specific patterns of drug use to sexual and injection-related risk behaviors among street youth. In general, drug use was quite high in this population, in some cases exceeding levels found in other studies of street youth (Kipke et al., 1995; Kral et al., 1997). Lifetime and current use of LSD and speed were particularly elevated relative to use seen among similar populations of youth in New York and San Diego (Kipke et al., 1995). As we have noted in a previous report
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Table 3 Sexual risk behaviors of current non-users and users of heroin and stimulants among street youth in Northern California Sexual risk behavior
No heroin or stimulant use (n= 527)
Primary stimulant use (n =231) OR (95%CI)
Primary heroin use (n =124) OR (95%CI)
Combined heroin/stimulant use (n =239) OR (95%CI)
Casual sex partner in past month \1 sex partner in past month Use of drugs/alcohol at last intercourse, main partnera,c Use of drugs/alcohol at last intercourse, casual partnerb,d History of sex tradec
1.0 (reference)
2.2 (1.6 – 3.1)
ns
2.7 (1.9 – 3.7)
1.0 (reference) 1.0 (reference)
2.0 (1.4 – 2.9) 2.0 (1.1 – 3.5)
ns 2.2 (1.1 – 4.2)
2.4 (1.7 – 3.4) 3.6 (2.1 – 6.1)
1.0 (reference)
ns
ns
2.3 (1.3 – 4.2)
1.0 (reference)
1.9 (1.2 – 3.0)
ns
2.4 (1.6 – 3.8)
a
Of those who had sex with a main partner in the past month (n = 392). Of those who had sex with a casual partner in the past month (n = 371). c n missing =3. d n missing =4. ns, not significant. b
(Gleghorn et al., 1997), this high use may be related to our recruitment methods: street-based sampling strategies may be more successful in locating high risk youth than recruitment in clinics and shelter settings. The use of multiple drugs by youth reflects trends noted in a recent national survey which reported that ‘‘teens and young adults enter treatment with a number of these drugs and alcohol, rather than a single drug, as their primary problem,’’ (Office of National Drug Control Policy, 1996). We found that youth currently using any heroin, cocaine or speed exhibited more HIV risk behavior in their sexual activities than youth not using these drugs. In addition, combined heroin/stimulant users and primary stimulant users appeared to be at greatest sexual risk. While the association of self-reported gay/lesbian/ bisexual orientation with use of heroin and stimulants among youth may be related to previously reported use of stimulants during sex by gay and bisexual men (Gorman, 1996), we observed a discrepancy between reported sexual identity and recent same-sex sexual activity. Further exploration of this issue in a larger sample of youth with gay/lesbian/bisexual orientation is warranted. In evaluating injection behaviors, combined heroin/ stimulant injectors engaged in higher risk injection practices than primary heroin or stimulant users. The HIV risk practices among the heroin/stimulant injectors may be related to greater severity of addiction in this group. Reports from field staff suggest that youth who use combinations of these drugs show greater drug dependence, and tend to use whatever substance is most conveniently available to quell drug cravings or withdrawal symptoms. This group may therefore take more risks in satisfying their drug habit (i.e. backloading)
than more casual users who may more easily resist use under unsafe conditions. Although this study did not include measures of addiction severity, the combined heroin/stimulant injector group reported longer duration of injection drug use than the other IDU categories (PB 0.05, results not shown). These results are consistent with previous research which suggests that combined use of both heroin and stimulants is associated with greater psychopathology and reduced responsiveness to treatment (Cunningham et al., 1996). Although high levels of current cocaine and crack use have been noted in other recent studies of street youth (Greene et al., 1997; Kipke et al., in press), the number of primary cocaine users in this sample was relatively small. This finding may reflect the use of speed as ‘the poor man’s cocaine’ (Gorman, 1996), or may be related to local drug availability and drug preferences. Although the small number of primary cocaine users limited our power to differentiate further between groups of stimulant users, the association of stimulant use with sexual risk behaviors among youth are consistent with previous reports of adult cocaine (Hudgins et al., 1995; Joe and Simpson, 1995; Longshore and Anglin, 1995) and speed users (Harris et al., 1993; Klee, 1993; Crofts et al., 1994; Ka¨ll, 1994; Stone et al., 1995). Limitations of this study include the use of self-report data, which can produce recall bias and socially desirable responses, thereby leading to inflation or underestimation of reported drug use. We took efforts to minimize these effects by having staff who were unaffiliated with service agencies conduct interviews, and by encouraging youth to respond honestly. Our study endeavored to limit recall bias by restricting drug use categories to use within the past month; this differs from several previous studies which categorized users
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225
Table 4 Injection characteristics and risk behaviors among currenta primary heroin, primary stimulant and combined heroin/stimulant users Injection characteristic/risk behaviors
Total current injectors (n= 231)
Primary stimulant injection (n= 45)
Primary heroin injection (n = 66)
Combined heroin/stimulant injection (n =120)
Kruskall-Wallis P value
Mean age at first injection of any drugb Mean number of injections with any drug in past monthb
16.9
16.8
17.8
16.4
0.008b
30.5
15.5
24.1
40.4
0.009b
HIV risk behaviors
n (%)
n (%)
n (%)
n (%)
Chi-square P Value
Share syringe in past monthc Ever share cookersd Ever backloade Use non-sterile syringe at last injectionf Ever inject without cleaning injection siteg Ever have others administer injectionsg
122 157 105 115
17 31 15 16
35 47 24 3
(78) (70) (64) (50)
(68) (69) (48) (36)
(81) (72) (50) (51)
70 83 66 66
(81) (70) (78) (56)
189 (82)
33 (73)
51 (79)
105 (88)
93 (56)
15 (47)
30 (63)
48 (56)
ns ns 0.001 0.08 0.07 ns
a
During the past month. n missing =64. c n missing =76. d n missing =8. e n missing =67. f n missing = 2. g n missing = 1. ns, not significant. b
according to lifetime use (Garfein et al., 1996), and use within the previous 6 months (Stone et al., 1995). Our ability to detect differences between drug use groups may be limited due to the small cell sizes for some drug use categories, particular IDU categories. In addition, our questionnaire did not assess severity of drug dependence, drug preferences, or injection frequency of specific drugs; therefore, our drug use categories may combine recent casual users with youth having more serious drug use habits. Future studies evaluating sexual and injection risk behaviors should use more precise measures of drug use in defining these categories, and differentiate youth who may be experimenting with different drugs from youth with heavy drug use. Finally, the design of the study did not allow evaluation of drug use categories over time. Street youth may progress from primary drug use, to use of drug combinations; alternatively, street youth may experiment using multiple substances concurrently before adopting a primary drug of choice. Although the longer duration of IDU found among the combined heroin/stimulant injectors suggests a progression to more intense drug use, future studies using qualitative and quantitative methods should evaluate the natural history of drug use among street youth. Given the extremely high levels of drug use and often concomitant sexual risk, there is an urgent need for
youth-specific drug treatment and comprehensive harm reduction services targeting both the sexual and drugrelated risk behaviors of these high risk youth. In designing interventions, most HIV prevention programs for youth do not differentiate between drugs the youth are currently using. Because of the differences in risk behaviors between users of different drugs, prevention programs should assess recent drug use among youth clients in order to more precisely tailor their interventions. Acknowledgement of recent use of multiple drugs, particularly heroin and stimulants, may suggest a youth who has a more generalized pattern of high risk behaviors, and who should be targeted for comprehensive prevention, support, and treatment services. The elevated levels of homelessness of the combined heroin/ stimulant users suggest that these youth may also need more support and survival services, including housing, meals, and health care.
Acknowledgements This study was supported by Centers for Disease Control and Prevention cooperative agreement U62/ CCU907200-04. We would like to acknowledge Tia Elena Martinez, and Joe Guydish for their helpful insights on the background and analysis for this paper.
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We would like to thank the following individuals and organizations for their assistance with this project: Matthew Boman, Clare Brown, Ralph Dickinson, Heather Hamilton, Leatha Jones, Tia Elena Martinez, Sue Miller, Henry Padilla, Lorna Sumaraga, and Amy Symons (SFDPHAO interviewers); Arthur DeGuzman, Aida Flandez, Delia Garcia, Lisa Graybill, Vince Guilin, Jan Gurley, Tim Kellogg, Ruth Kinney, Priscilla Lee-Chu, David Makofsky, Stephen Mills (SFDPHAO staff); Michael Clatts, Michele Kipke (AESOP youth-site investigators); and John Anderson, Judith Greenberg, and Matthew Seeman (CDC).
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Gable, R.S., 1993. Toward a comparative view of dependence potential and acute toxicity of psychoactive substances used non-medically. Am. J. Drug Alcohol Abuse 19, 263 – 281. Garfein R.S., Doherty, M.C., Brown, D., Huang, H., Patania, S.S., Vlahov, D., 1996. Risk-taking behaviors among short-term injecing drug users associated with type of drug injected. Presented at the XI International Conference on AIDS (Abstract Tu.C.2535), Vancouver, Canada, July 7 – 12. Gleghorn, A.A., Clements, K.D., Marx, R., Vittinghoff, E., Lee-Chu, P., Katz, M., 1997. The impact of intensive outreach on HIV prevention activities of homeless, runaway, and street youth in San Francisco: The AIDS Evaluation of Street Outreach Project (AESOP). AIDS Behav. 1 (4), 263 – 273. Gorman, M., 1996. Speed use and HIV transmission. Focus June, 4 – 6. Gossop, M., Griffiths, P., Powis, B., Strang, J., 1993. Severity of heroin dependence and HIV risk. I. Sexual behaviour. AIDS Care 5 (2), 149 – 157. Greene, J.M., Ennett, S.T., Ringwalt, C.L., 1997. Substance use among runaway and homeless youth in three national samples. Am. J. Public Health 87, 229 – 235. Harris, N., Thiede, H., McGough, J., et al., 1993. Risk factors for HIV infection among injection drug users: results of blinded surveys in drug treatment centers, King County, Washington. J. AIDS 6 (1), 1275 – 1282. Hudgins, R., McCusker, J., Stoddard, A., 1995. Cocaine use and risky injection and sexual behaviors. Drug Alcohol Depend. 37, 7 – 14. Joe, G.W., Simpson, D.D., 1995. HIV risks, gender, and cocaine use among opiate users. Drug Alcohol Depend. 37, 23 – 28. Ka¨ll, K., 1994. The risk of HIV infection for noninjecting sex partners of injecting drug users in Stockholm. AIDS Educ. Prev. 6 (94 (Aug.), 351 – 364. Kipke, M.D., O’Connor, S., Palmer, R., MacKenzie, R.G., 1995. Street youth in Los Angeles: Profile of a group at high risk for human immunodeficiency virus infection. Arch. Pediatr. Adolesc. Med. 149, 513 – 519. Kipke, Clatts, Garcia, Palmer, Seeman, in press. Substance use and injection drug use among street youth in four US cities. Am. J. Public Health. Klee, H., 1993. HIV risks for women drug infectors: heroin and amphetamine users compared. Addiction 88 (8 (Aug.), 1055– 1062. Kral, A.H., Molnar, B.E., Booth, R.E., Watters, J.K., 1997. Prevalence of sexual risk behavior and substance use among runaway and homeless adolescents in San Francisco, Denver, and New York City. Int. J. STD AIDS 8, 109 – 117. Longshore, D., Anglin, M.D., 1995. Number of sex partners and crack cocaine use: Is crack an independent marker for HIV risk behavior? J. Drug Issues 25 (1), 1 – 10. MacKellar, D.A., Valleroy, L., Janssen, R., Jacobs, T., 1996. HIV prevalence, risk factors, and predictors of unprotected sex among homeless and runaway youth in four US communities. Presented at the XI International Conference on AIDS (Abstract Tu.C.2651), Vancouver, Canada, July 7 – 12. Office of National Drug Control Policy, 1996. Pulse Check: National Trends in Drug Abuse Fall 1996, Washington, DC. Ross, M.W., Kelaher, M., Wodak, A., Gold, J., 1994. Predictors of intoxicated sex in injecting drug users. J. Addict. Dis. 13 (2), 69 – 80. Rotheram-Borus, M.J., Koopman, C., Ehrhardt, A.A., 1991. Homeless youths and HIV infection. Am. Psychol. 46, 1188 – 1197. Shalwitz, J., Goulart, M., Dunnigan, K., Flannery, D., 1990. Prevalence of sexually transmitted diseases (STD) and HIV in a homeless youth medical clinic in San Francisco. Paper presented at the Sixth International Conference on AIDS, San Francisco, CA.
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L.F., 1991. HIV seroprevalence in a facility for runaway and homeless adolescents. Am. J. Public Health 81, 50 – 53. Titus, S., Marmor, M., Des Jarlais, D., Kim, M., Wolfe, H., Beatrice, S., 1994. Bleach use and HIV seroconversion among New York City injection drug users. J. AIDS 7 (7 (July), 700 – 704.
Association between drug use patterns and HIV risks among homeless, runaway, and street youth in Northern California Alice A. Gleghorn *, Rani Marx, Eric Vittinghoff, Mitchell H. Katz San Francisco Department of Public Health, AIDS Office, 25 Van Ness A6enue, Suite 500, San Francisco, CA 94102 -6033, USA Received 27 August 1997; accepted 8 February 1998
Abstract We examined relationships between drug use patterns and HIV risk behaviors among 1121 street-recruited homeless, runaway, and ‘street youth’ in Northern California. Comparisons demonstrated that youth using any heroin, methamphetamine, or cocaine exhibited more sexual risks than non-users, while primary stimulant and combined heroin/stimulant users showed greatest sexual risk. Combined heroin/stimulant injectors showed higher risk injection practices than primary heroin or primary stimulant injectors, including frequent injections and backloading syringes. Interventions for street youth should be tailored to current drug use patterns since those using combinations of heroin and stimulants may require more comprehensive prevention, support and treatment services. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Homeless; Street youth; Human immunodeficiency virus; Drug use patterns; Prevention; Injection drug use
1. Introduction Homeless, runaway, and ‘street’ youth (youth involved in the illegal street economies of drugs, prostitution, theft, or panhandling) are at risk for HIV infection through both sexual and drug-related behaviors (Rotheram-Borus et al., 1991). Previous studies of these youth (hereafter referred to as ‘street’ youth) have found high rates of drug use (MacKellar et al., 1996; Kral et al., 1997; Kipke et al., in press), and a majority (79%) of these youth acknowledge a history of using drugs associated with high fatality risk and high dependency potential such as methamphetamine (speed), cocaine, heroin and alcohol (Kipke et al., 1995). Up to 43% of street youth report ever injecting drugs (Kral et al., 1997), 43% report a history of trading sex for food, money, drugs or shelter (Kipke et al., 1995), a majority (median prevalence 58%) have recent episodes of unprotected sex (MacKellar et al., 1996), and 75% report ever having sex while under the influence of drugs or * Corresponding author. Tel.: +1 415 2553722.
alcohol (Kral et al., 1997). Among street youth who inject drugs, rates of sharing needles and syringes range from 59% (Kipke et al., 1995) to 62% (Kral et al., 1997). HIV seroprevalence is also high among street youth tested in clinics, ranging from 5.3% (Stricof et al., 1991) to 8.2% (Shalwitz et al., 1990). Since different drugs have different physiological effects, use of a particular drug or combinations of drugs may correspond to different patterns of use, dependence, associated risk behaviors, and response to treatment (Klee, 1993; Darke et al., 1994; Cunningham et al., 1996). Several studies of drug use patterns in adult populations of injection drug users (IDUs) and gay/bisexual men have suggested a link between use of cocaine (Cohen et al., 1994; Bux et al., 1995; Hudgins et al., 1995; Joe and Simpson, 1995; Longshore and Anglin, 1995; Camacho et al., 1996), methamphetamine (Harris et al., 1993; Klee, 1993; Crofts et al., 1994; Ka¨ll, 1994; Stone et al., 1995), heroin (Gossop et al., 1993; Klee, 1993; Baker et al., 1994; Ross et al., 1994; Bux et al., 1995), or speedball (use of heroin and cocaine together) (Titus et al., 1994; Camacho et al., 1996;
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Brackbill et al., 1997) and HIV risk behaviors or HIV serostatus. Few studies have evaluated patterns of drug use among youth. Gorman (1996) noted that speed use (both injection and non-injection use) is especially popular among younger gay and bisexual men. Garfein et al. (1996) studied IDUs between the ages of 18 and 25, and found that a history of injecting cocaine was associated with HIV infection, as well as with other high risk sexual and drug use behaviors. In a study of street youth (Kipke et al., 1995), evaluated drugs with high fatality risk as a class and noted a relationship between use of these ‘high risk’ drugs (Gable, 1993) and a history of sexually transmitted disease, survival sex (trading sex for food, money, drugs or shelter), multiple sex partners, and being ‘high’ on drugs or alcohol during last sexual intercourse. However, that study did not differentiate between use of specific drugs and risk behaviors. To our knowledge, the relationship between HIV risk behaviors and specific drug use patterns among street youth has not been evaluated. To address these issues, the current study reports on patterns of drug use among a street-recruited population of homeless, runaway and street youth, and the relationship of these patterns to sexual and injection-related risk behaviors.
2. Method
2.1. Recruitment Subjects for this study were recruited as part of the Centers for Disease Control and Prevention (CDC) funded AIDS Evaluation of Street Outreach Project, or AESOP. AESOP targeted the risk behaviors of high risk populations of street youth and IDUs in eight metropolitan areas with a variety of outreach strategies. Specific details are provided elsewhere for the overall project (Anderson et al., 1996), for the Northern California site (Clements et al., 1997) and for the San Francisco intervention (Gleghorn et al., 1997). Data for Northern California were collected in separate intervention (San Francisco) and comparison sites (Berkeley, Santa Cruz and Arcata). The four recruitment cities were selected through preliminary ethnographic research for having similar populations of street youth who congregate in public locations, such as parks and street corners. The survey was conducted in a series of sequential cross-sectional data collection periods. Following an initial assessment conducted from January 1993 to August 1993, four additional survey periods roughly 3.5 months long were conducted with a break of approximately 2 months between survey periods ending in October, 1995. A total 1795 youth were approached for
interviews. There was a 17% refusal rate, and a 72% eligibility rate. Of the youth eligible for the study, 93% completed an interview. Deleting duplicates, a total of 1121 interviews were included in this analysis. Since preliminary analysis determined that implementation of the AESOP intervention in San Francisco was not associated with changes in drug use, the current analysis combines data across all waves from the four recruitment sites. Youth were recruited for this study using the streetbased sampling methods described in Clatts et al. (1995), Anderson et al. (1996) and Clements et al. (1997). This sampling strategy was designed to assure that youth sampled from a given location were representative of all youth present during a given sampling period. In each city, potential recruitment locations were identified and monitored for youth activity during preliminary research. Locations with adequate numbers of youth were selected as subject recruitment sites. The number of interviews to be obtained from each site was calculated from the pilot observations to correspond to the expected available samples. To recruit subjects for the study, interviewers visually assessed each recruitment site for the presence of target youth, counted the available youth and approached every second youth who appeared to meet the age criteria for screening. Eligibility was determined through a brief discussion with the youth. Eligibility criteria included youth between the ages of 12 and 23 years old who were: (1) currently homeless (for at least 2 months), and/or (2) who had experienced repeated periods of homelessness over the past 12 months, and/ or (3) who were engaged in the street economy (prostitution, drug sales, theft, panhandling, pornography or selling stolen property).
2.2. Procedures Interviewers briefly described the study to eligible youth, acquired verbal consent from interested participants, and accompanied the youth to a semi-private location where the interview was conducted. Youth received a $20 remuneration for their participation in the 30–40-min interview. In addition, the interviewer purchased a small meal (up to $5 value) for the youth’s consumption during the interview. The study design, questionnaire and consent procedures were reviewed and approved by the Institutional Review Board of the University of California, San Francisco.
2.3. Measures The survey instrument was developed by the CDC for use at all AESOP sites. The questionnaire assessed demographic characteristics including gender, age, ethnicity, and current homelessness. Sexual behaviors were
A.A. Gleghorn et al. / Drug and Alcohol Dependence 51 (1998) 219–227
also assessed, including sexual orientation, recent sexual activity with main or casual partners, and sexual risk behaviors (i.e. recent casual sex partner, more than one sex partner in the past month, anal sex during the past month, use of any drug (including alcohol) during last vaginal sex with main or casual partner, no condom use during last sex with a main or casual partner, and a history of trading sex for money, food, drugs or shelter). History of drug use and drug use within the last 30 days were assessed for the following substances: cocaine, heroin, speed, speedball, crack, ecstasy, nitrous oxide, LSD and hallucinogens other than LSD (mushrooms, peyote, or mescaline). Injection during the last 30 days was assessed for heroin, speed, speedball, cocaine, ecstasy, and LSD. Variables related to injection history included history of injecting any drug, and age at first injection of any drug. Injection-related HIV risk practices assessed were: total number of injections of any drug during the past 30 days, any sharing of syringes in the past 30 days, no use of bleach at last injection, use of a non-sterile syringe at last injection, and history of backloading syringes (i.e. the use of one syringe to fill another with drugs), sharing cookers, having others prepare and administer injections, or injecting without cleaning the injection site. In defining categories of recent drug use, we focused on differentiating patterns of recent speed, cocaine (including crack) and heroin use. Category determination was made based on reported use during the past month (through snorting, swallowing, smoking, or injecting) of heroin, speed, and cocaine. Categorization was guided by field observations of youth drug use behaviors, drug use history, and overlap between recent use of speed, cocaine, and heroin. According to outreach worker observations, patterns of speed and cocaine use among these youth are fluid, subject to drug availability and street price, with cocaine typically being less accessible. Therefore, for the majority of analyses, recent use of cocaine and/or speed was analyzed as a primary stimulant category. In examining differences in the sexual risk behaviors of subcategories of stimulant users (primary cocaine, primary speed, and combined speed and cocaine), only exploratory analyses were conducted due to small cell sizes. In addition, a distinct subgroup of youth tends to use whatever drug is most readily available, resulting in the use of combinations of drugs during a 30-day period. Therefore, youth were divided into four mutually exclusive categories of drug use: use of heroin and stimulants (combined heroin/stimulant category); use of heroin without use of stimulants (primary heroin category); use of stimulants without heroin (primary stimulant category); and no use of heroin, or stimulants (no heroin, or stimulants category).
221
2.4. Analysis Chi-square analyses were conducted to detect differences between demographic characteristics, sexual variables, and injection risk activities by recent drug use categories. To evaluate the relationship between HIV sexual risk behaviors by current drug use patterns, bivariate odds ratios were calculated. The KruskalWallis test was conducted to evaluate differences in number of injections during the past month and age of first injection between injection categories.
3. Results
3.1. Demographic characteristics and sexual acti6ity The sample was predominately heterosexual (78%), white (86%), and currently homeless (84%) (Table 1). Nearly two-thirds (62%) were over 18 years of age, and 64% were male (results not shown). Almost two-thirds of the youth (63%) reported vaginal intercourse during the past 30 days; of these sexually active youth, vaginal sex with a main partner only was reported by 48% of the sample, sex with only casual partners was reported by 45%, and sex with both types of partners in the past month was reported by 7%. Few youth (4%) engaged in anal sex in the past month.
3.2. Drug use history and recent use Virtually all youth (99.9%) reported lifetime use of some drug (Table 2). The most common drugs that youth reported ever using were: LSD, marijuana, hallucinogens other than LSD, alcohol, nitrous oxide, cocaine, heroin, speed, and speedball. Thirty-nine percent of the sample reported ever injecting drugs. Nearly all youth (95%) reported drug use within the past month (Table 2). Marijuana, alcohol, and LSD were the most frequently used drugs. One-fifth (21%) of the youth had injected any drugs during the past 30 days; the most commonly injected drugs were heroin, speed, speedball, and cocaine. One-fifth of the sample were primary stimulant users; subcategories of these youth (results not shown) included few (3%, n= 39) who used cocaine or crack alone in the past month, slightly more (5%, n = 51) who reported use of both cocaine and speed, and a greater proportion (13%, n= 141) who reported use of speed but not cocaine.
3.3. Comparisons of demographic characteristics and sexual risks between recent drug use categories There were no gender or age differences by current drug use (results not shown). Whites were significantly
48 (9)
(85) (78) (18) (57) (24) (16) (29)
149 (13)
446 409 93 299 127 82 56 85 (67)
(86) (84) (22) (63) (33) (21) (40)
248 (68)
964 936 248 710 371 239 156
No heroin or stimulant Use (n =527) n (%)
b
Within the past month. Of those who had sex with a main partner in the past month (n =392). c Of those who had sex with a casual partner in the past month (n = 371). d n missing= 1. e n missing=3. f n missing= 4.
a
White Currently homeless Gay/lesbian/bisexual orientationd Vaginal sex with any partnera Casual sex partnera \1 sex partnera Use of drugs/alcohol at last intercourse, main partnerb,e Use of drugs/alcohol at last intercourse, casual partnerc,f History of trading sex for money, food, drugs, or sheltere
Total sample (n= 1121) n (%) (82) (85) (27) (66) (42) (27) (45)
37 (16)
54 (56)
189 196 63 153 96 62 30
Primary stimulant use (n =231) n (%)
17 (14)
22 (58)
114 (93) 105(85) 31 (25) 80 (65) 38 (31) 22 (18) 21 (47)
Primary heroin use (n =124) n (%)
Table 1 Demographic characteristics and sexual risk behaviors by current drug usea among street youth in Northern California
(90) (95) (26) (75) (46) (31) (59)
47 (20)
87 (82)
215 226 61 178 110 73 49
Combined heroin/stimulant use (n= 239) n (%)
0.001
0.001
0.01 0.001 0.008 0.001 0.001 0.001 0.001
Chi-square, P value
222 A.A. Gleghorn et al. / Drug and Alcohol Dependence 51 (1998) 219–227
A.A. Gleghorn et al. / Drug and Alcohol Dependence 51 (1998) 219–227
223
Table 2 Lifetime, current use and current injection drug use among street youth in Northern California Drug (n =1121)
Ever used n (%)
Current usea n (%)
Use of any drugc Use of any injected drugd LSDe Peyote/mescaline/mushrooms Nitrous oxidee Speedd Heroin Cocainef Crackf Speedball Ecstasy Alcohol Marijuana
1120 435 1080 1023 917 854 834 834 557 807 612 938 1028
1062 234 555 327 246 377 354 161 136 84 165 597 847
(99.9) (39.0) (96.6) (91.3) (82.0) (76.5) (74.4) (74.7) (49.9) (72.3) (54.8) (83.7) (91.7)
(94.7) (21.0) (49.5) (29.2) (21.9) (33.6) (31.6) (14.4) (12.1) (7.5) (14.7) (53.3) (75.6)
Current injectionb n (%)
6 (2.6)
135 (57.7) 183 (78.2) 60 (25.6) 63 (26.9) 14 (6.0)
a
Within the past month. Among injection drug users during the past month. c Including alcohol and marijuana. d n missing =5. e n missing =3. f n missing = 4. b
more likely to report primary heroin use than nonwhites (Table 1). Current homelessness and sexual orientation also differed by drug use categories: combined heroin/stimulant users were nearly all homeless; and primary stimulant users, combined heroin/stimulant users, and primary heroin users more often reported gay/lesbian/bisexual sexual orientation. There were no significant differences with respect to condom use at last sex with any partner, or recent anal sex (results not shown). However, there were significant differences in the following sexual risk behaviors for recent drug use categories: combined heroin/stimulant users were more likely to have a casual sex partner, have more than one sex partner in the past month, use drugs at last intercourse with a main or casual partner, or ever trade sex compared to other drug users (Table 1). We compared sexual risk behaviors which were significant in chi-square analyses between users and nonusers of heroin and stimulants (Table 3). Combined heroin/stimulant users and primary stimulant users had significantly more sexual risk behaviors than nonusers. In our exploratory analysis, primary cocaine users showed elevated risks related to casual sex partners (results not shown), including having a recent casual sex partner (54%), having more than one recent sex partner (33%), and using drugs during last sex with a casual sex partner (81%). A majority of primary cocaine (82%) and combined speed and cocaine users (85%) did not use condoms during last intercourse with a main partner, while combined speed and cocaine users showed the highest percentage of using drugs at last sex with a main partner (69%). During their most recent sexual encounter with a casual partner, primary
speed users were least likely to use drugs (49%), but were the most likely to have unprotected sex with a casual partner (60%).
3.4. Injection acti6ities Table 4 presents injection risk activities by injection drug use category. Comparisons of injection behaviors between combined heroin/stimulant IDUs and other injection drug categories revealed several contrasts. Age at first injection of any drug and ever using one syringe to load another (backloading) differed significantly across injection drug use categories: combined heroin/ stimulant injectors initiated injection at the youngest age and were more likely to backload than other drug users. The number of injections in the last 30 days also differed significantly across drug use categories: primary stimulant injectors reported the lowest number of injections per month, while combined heroin/stimulant injectors reported the highest.
4. Discussion This study expands findings of previous work by relating specific patterns of drug use to sexual and injection-related risk behaviors among street youth. In general, drug use was quite high in this population, in some cases exceeding levels found in other studies of street youth (Kipke et al., 1995; Kral et al., 1997). Lifetime and current use of LSD and speed were particularly elevated relative to use seen among similar populations of youth in New York and San Diego (Kipke et al., 1995). As we have noted in a previous report
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Table 3 Sexual risk behaviors of current non-users and users of heroin and stimulants among street youth in Northern California Sexual risk behavior
No heroin or stimulant use (n= 527)
Primary stimulant use (n =231) OR (95%CI)
Primary heroin use (n =124) OR (95%CI)
Combined heroin/stimulant use (n =239) OR (95%CI)
Casual sex partner in past month \1 sex partner in past month Use of drugs/alcohol at last intercourse, main partnera,c Use of drugs/alcohol at last intercourse, casual partnerb,d History of sex tradec
1.0 (reference)
2.2 (1.6 – 3.1)
ns
2.7 (1.9 – 3.7)
1.0 (reference) 1.0 (reference)
2.0 (1.4 – 2.9) 2.0 (1.1 – 3.5)
ns 2.2 (1.1 – 4.2)
2.4 (1.7 – 3.4) 3.6 (2.1 – 6.1)
1.0 (reference)
ns
ns
2.3 (1.3 – 4.2)
1.0 (reference)
1.9 (1.2 – 3.0)
ns
2.4 (1.6 – 3.8)
a
Of those who had sex with a main partner in the past month (n = 392). Of those who had sex with a casual partner in the past month (n = 371). c n missing =3. d n missing =4. ns, not significant. b
(Gleghorn et al., 1997), this high use may be related to our recruitment methods: street-based sampling strategies may be more successful in locating high risk youth than recruitment in clinics and shelter settings. The use of multiple drugs by youth reflects trends noted in a recent national survey which reported that ‘‘teens and young adults enter treatment with a number of these drugs and alcohol, rather than a single drug, as their primary problem,’’ (Office of National Drug Control Policy, 1996). We found that youth currently using any heroin, cocaine or speed exhibited more HIV risk behavior in their sexual activities than youth not using these drugs. In addition, combined heroin/stimulant users and primary stimulant users appeared to be at greatest sexual risk. While the association of self-reported gay/lesbian/ bisexual orientation with use of heroin and stimulants among youth may be related to previously reported use of stimulants during sex by gay and bisexual men (Gorman, 1996), we observed a discrepancy between reported sexual identity and recent same-sex sexual activity. Further exploration of this issue in a larger sample of youth with gay/lesbian/bisexual orientation is warranted. In evaluating injection behaviors, combined heroin/ stimulant injectors engaged in higher risk injection practices than primary heroin or stimulant users. The HIV risk practices among the heroin/stimulant injectors may be related to greater severity of addiction in this group. Reports from field staff suggest that youth who use combinations of these drugs show greater drug dependence, and tend to use whatever substance is most conveniently available to quell drug cravings or withdrawal symptoms. This group may therefore take more risks in satisfying their drug habit (i.e. backloading)
than more casual users who may more easily resist use under unsafe conditions. Although this study did not include measures of addiction severity, the combined heroin/stimulant injector group reported longer duration of injection drug use than the other IDU categories (PB 0.05, results not shown). These results are consistent with previous research which suggests that combined use of both heroin and stimulants is associated with greater psychopathology and reduced responsiveness to treatment (Cunningham et al., 1996). Although high levels of current cocaine and crack use have been noted in other recent studies of street youth (Greene et al., 1997; Kipke et al., in press), the number of primary cocaine users in this sample was relatively small. This finding may reflect the use of speed as ‘the poor man’s cocaine’ (Gorman, 1996), or may be related to local drug availability and drug preferences. Although the small number of primary cocaine users limited our power to differentiate further between groups of stimulant users, the association of stimulant use with sexual risk behaviors among youth are consistent with previous reports of adult cocaine (Hudgins et al., 1995; Joe and Simpson, 1995; Longshore and Anglin, 1995) and speed users (Harris et al., 1993; Klee, 1993; Crofts et al., 1994; Ka¨ll, 1994; Stone et al., 1995). Limitations of this study include the use of self-report data, which can produce recall bias and socially desirable responses, thereby leading to inflation or underestimation of reported drug use. We took efforts to minimize these effects by having staff who were unaffiliated with service agencies conduct interviews, and by encouraging youth to respond honestly. Our study endeavored to limit recall bias by restricting drug use categories to use within the past month; this differs from several previous studies which categorized users
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225
Table 4 Injection characteristics and risk behaviors among currenta primary heroin, primary stimulant and combined heroin/stimulant users Injection characteristic/risk behaviors
Total current injectors (n= 231)
Primary stimulant injection (n= 45)
Primary heroin injection (n = 66)
Combined heroin/stimulant injection (n =120)
Kruskall-Wallis P value
Mean age at first injection of any drugb Mean number of injections with any drug in past monthb
16.9
16.8
17.8
16.4
0.008b
30.5
15.5
24.1
40.4
0.009b
HIV risk behaviors
n (%)
n (%)
n (%)
n (%)
Chi-square P Value
Share syringe in past monthc Ever share cookersd Ever backloade Use non-sterile syringe at last injectionf Ever inject without cleaning injection siteg Ever have others administer injectionsg
122 157 105 115
17 31 15 16
35 47 24 3
(78) (70) (64) (50)
(68) (69) (48) (36)
(81) (72) (50) (51)
70 83 66 66
(81) (70) (78) (56)
189 (82)
33 (73)
51 (79)
105 (88)
93 (56)
15 (47)
30 (63)
48 (56)
ns ns 0.001 0.08 0.07 ns
a
During the past month. n missing =64. c n missing =76. d n missing =8. e n missing =67. f n missing = 2. g n missing = 1. ns, not significant. b
according to lifetime use (Garfein et al., 1996), and use within the previous 6 months (Stone et al., 1995). Our ability to detect differences between drug use groups may be limited due to the small cell sizes for some drug use categories, particular IDU categories. In addition, our questionnaire did not assess severity of drug dependence, drug preferences, or injection frequency of specific drugs; therefore, our drug use categories may combine recent casual users with youth having more serious drug use habits. Future studies evaluating sexual and injection risk behaviors should use more precise measures of drug use in defining these categories, and differentiate youth who may be experimenting with different drugs from youth with heavy drug use. Finally, the design of the study did not allow evaluation of drug use categories over time. Street youth may progress from primary drug use, to use of drug combinations; alternatively, street youth may experiment using multiple substances concurrently before adopting a primary drug of choice. Although the longer duration of IDU found among the combined heroin/stimulant injectors suggests a progression to more intense drug use, future studies using qualitative and quantitative methods should evaluate the natural history of drug use among street youth. Given the extremely high levels of drug use and often concomitant sexual risk, there is an urgent need for
youth-specific drug treatment and comprehensive harm reduction services targeting both the sexual and drugrelated risk behaviors of these high risk youth. In designing interventions, most HIV prevention programs for youth do not differentiate between drugs the youth are currently using. Because of the differences in risk behaviors between users of different drugs, prevention programs should assess recent drug use among youth clients in order to more precisely tailor their interventions. Acknowledgement of recent use of multiple drugs, particularly heroin and stimulants, may suggest a youth who has a more generalized pattern of high risk behaviors, and who should be targeted for comprehensive prevention, support, and treatment services. The elevated levels of homelessness of the combined heroin/ stimulant users suggest that these youth may also need more support and survival services, including housing, meals, and health care.
Acknowledgements This study was supported by Centers for Disease Control and Prevention cooperative agreement U62/ CCU907200-04. We would like to acknowledge Tia Elena Martinez, and Joe Guydish for their helpful insights on the background and analysis for this paper.
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We would like to thank the following individuals and organizations for their assistance with this project: Matthew Boman, Clare Brown, Ralph Dickinson, Heather Hamilton, Leatha Jones, Tia Elena Martinez, Sue Miller, Henry Padilla, Lorna Sumaraga, and Amy Symons (SFDPHAO interviewers); Arthur DeGuzman, Aida Flandez, Delia Garcia, Lisa Graybill, Vince Guilin, Jan Gurley, Tim Kellogg, Ruth Kinney, Priscilla Lee-Chu, David Makofsky, Stephen Mills (SFDPHAO staff); Michael Clatts, Michele Kipke (AESOP youth-site investigators); and John Anderson, Judith Greenberg, and Matthew Seeman (CDC).
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