Correlates of consistent condom use with main partners by partnership patterns among young adult male injection drug users from five US cities

Drug and Alcohol Dependence 91S (2007) S56–S63

Correlates of consistent condom use with main partners by partnership patterns among young adult male injection drug users from five US cities夽 F. Kapadia a,∗ , M.H. Latka a,1 , S.M. Hudson b , E.T. Golub c , J.V. Campbell d , S. Bailey e , V. Frye a , R.S. Garfein f,2 , for the DUIT Study Team a

Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY 10029, USA b Health Research Association, Los Angeles, CA 90033, USA c Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD 21205, USA d Public Health Seattle and King County, Seattle, WA 98104, USA e University of Illinois at Chicago, School of Public Health, Chicago, IL 60612, USA f Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, GA 30017, USA Received 7 November 2006; received in revised form 10 January 2007; accepted 11 January 2007

Abstract This paper examined correlates of consistent condom use with a main partner among heterosexual male injection drug users (IDUs). Using data from a multi-site sample of young IDUs, we identified 1770 sexually active men of whom 24% (429/1770) reported an exclusive main female sex partner and 49% (862/1770) reported both main and casual female sex partners. Consistent condom use with a main partner was low among men with an exclusive main partner and those with multiple partners (12% and 17%, respectively). In multivariate analysis, consistent condom use with a main partner across partnership patterns was directly associated with anticipating a positive response to requests for condom use and by partner support of condom use; consistent condom use was inversely associated with a main partner’s pregnancy desires. Among men with an exclusive main partner, consistent condom use was also inversely associated with needle sharing with a main partner. Among men with multiple partners, consistent condom use with a main partner was inversely associated with injecting with a used needle and intimate partner violence. The low prevalence of consistent condom use with main female partners among heterosexually active male IDUs indicates an increased risk for HIV transmission between men and their primary sex partners. Interventions for heterosexual males that are geared toward increasing condom use in primary relationships are warranted. © 2007 Published by Elsevier Ireland Ltd. Keywords: Heterosexual males; Condom use; Sexual risk behaviors; Injection drug users

1. Introduction It is well established that injection drug users (IDUs) are at an increased risk for human immunodeficiency virus (HIV) transmission and acquisition due to unsafe injection practices. Recent 夽 The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. ∗ Corresponding author at: Guttmacher Institute, 120 Wall Street, 21st Floor, New York, NY 10005, USA. Tel.: +1 212 248 1111x2225; fax: +1 212 248 1951. E-mail address: [email protected] (F. Kapadia). 1 Present address: Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu Natal, Durban, South Africa. 2 Present address: University of California San Diego, School of Medicine, San Diego, CA 92093, USA.

0376-8716/$ – see front matter © 2007 Published by Elsevier Ireland Ltd. doi:10.1016/j.drugalcdep.2007.01.004

evidence indicates that among IDUs, risky sexual behaviors are independent risk factors for HIV transmission and that risky sex may be a more significant risk factor than injection behavior (Strathdee et al., 2001; Kral et al., 2001). Specifically, IDUs are more likely than non-IDUs to engage in unsafe sexual practices such as exchanging sex for money or drugs (Astemborski et al., 1994), having sex with multiple partners (Booth et al., 2000), having concurrent sexual partners, and having sex while intoxicated (Falck et al., 1997). These behaviors among male IDUs increase the risk of contracting HIV and transmitting it to sex partners. Female sex partners of male IDUs, particularly main female partners, are often unaware of their partners multiple risk factors for HIV and can be at increased risk for HIV acquisition (O’Leary, 2000; Harvey et al., 2004). A recent study by

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Fals-Stewart et al. (2003) sought to examine the extent of secondary HIV exposure risk to wives of men who engaged in either high-risk extramarital sex or injection practices. Their findings indicated that among a sample of husbands who had participated in either of these high-risk behaviors and had unprotected sex with their wives, 71% of wives were not aware that their husbands had engaged in these risk behaviors (Fals-Stewart et al., 2003). The consequence of this lack of knowledge is highlighted by recent Centers for Disease Control and Prevention (CDC) surveillance estimates indicating that a third of HIV-infected women report not knowing how they were infected. Further assessment of women with “unspecified” HIV risk reclassified two-thirds as “heterosexual contact” (National Center for HIV, STD, and TB Prevention, 2002). An unknown classification for mode of HIV acquisition suggests that women may be unaware of, or unwilling to learn or acknowledge the potential for HIV risk from primary male partners (O’Leary, 2000; Sobo, 1993). Further evidence suggests that many newly infected women acquired HIV from their primary male sex partners (Montgomery et al., 2003; Hader et al., 2001; O’Leary, 2000; Carpenter et al., 1991; Marmor et al., 1990). Efforts to stem heterosexual transmission of HIV are further complicated by differences in condom use by partner type. Although condom use among IDUs is more common with casual or sex-trade partners than main partners, the level of use may be insufficient to prevent HIV transmission (Tyndall et al., 2002; Falck et al., 1997). Trust and intimacy-seeking are predictors of condom use by IDUs in steady, monogamous relationships (O’Leary, 2000). Psychosocial characteristics including intention to use condoms, positive attitudes toward condoms and ability to advocate for condom use are associated with use among IDUs with casual partners (van Empelen et al., 2001; Malow et al., 1993). However, little is known about how these factors influence condom use in main relationships when men have sex with multiple types of partners (e.g., main and casual partners). Given that a significant proportion of male IDUs report multiple sex partners in addition to a main steady partner, we were interested in understanding factors associated with condom use among men with main female partners when they also have sex with casual female partners. This distinction is particularly important as concurrent sexual partnering significantly increases the risk for men’s acquisition of HIV as well as transmission of HIV to their main female partners (Flom et al., 2001). The purpose of this study was to identify factors associated with consistent condom use with main female partners in two groups of male IDUs, namely, those who only have a main female partner and those who have both main and casual female partners. Understanding which factors are associated with condom use in different partnership patterns can be used to enhance sexual risk-reduction components of HIV interventions. 2. Methods 2.1. Study design and sample Data for this report come from the baseline visit of the Collaborative Injection Drug Users Study-III/Drug Users Intervention Trial (CIDUS-III/DUIT), a

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multi-site, randomized behavioral intervention trial of a six-session intervention to reduce risky sexual and drug injection-related behaviors among HIV and HCV antibody-negative IDUs. Details of study objectives, design and methodology have been described elsewhere (Garfein et al., 2007). IDUs were recruited from Baltimore, Chicago, Los Angeles, New York, and Seattle. Individuals were eligible for this study if they were between 15 and 30 years old, reported injection drug use during the last 6 months, intended on residing in the study city in which they were recruited for at least 1 year following the baseline interview, agreed to antibody testing for HIV, hepatitis A, B and C virus (HAV, HBV and HCV) and were able to complete the assessment in English. All eligible participants provided written informed consent to participate, completed a behavioral assessment using audio computer-administered self-interview (ACASI), received pre-test counselling, and underwent venipuncture for serological testing. The protocol was approved by the Institutional Review Boards at CDC and participating organizations. Among the 3285 individuals enrolled in the DUIT study, 69% (2262/3285) were men, of which 78% (1770/2262) were sexually active during the 3 months preceding the baseline interview. Given our focus on examining sexual risk among heterosexual males, 246 men who reported same-sex or bisexual behaviors were excluded from this analysis. The analysis included two mutually exclusive groups of heterosexually active men who reported that in the prior 3 months they had engaged in vaginal or anal sex with a main female partner only (n = 429) or had engaged in vaginal or anal sex with a main female partner in addition to one or more other/casual female partners, hereafter referred to as the multiple partner group (n = 862). Men who reported sex with only other/casual female sex partners were excluded (n = 233). A main female partner was defined as someone the participant considered a close, steady partner such as a girlfriend, spouse, or significant other. Casual and other partners were defined as sexual partners other than a main, steady partner and included sex trade partners.

2.2. Dependent variable The primary outcome variable was self-reported use of male or female condoms during anal or vaginal sex with a main female sex partner. To determine the extent of condom use, participants first reported the number of times they had vaginal or anal sex separately by partner type during the 3 months preceding baseline interview. Next, participants reported the number of times they used a male or female condom during these sexual episodes. This information was used to calculate the proportion of protected sex acts per partner type. Condom use was initially categorized as consistent use (used every time), inconsistent use (which included individuals who reported at least one unprotected sex act), and no use (never used a condom). To avoid potential misclassification error, we further examined whether inconsistent condom users were more comparable to consistent users or never users (Crosby et al., 2004). Results indicated that inconsistent users were more similar to non-users with regard to sociodemographic characteristics and drug use practices and these categories were subsequently combined; thus, condom use was dichotomized as consistent versus inconsistent/no use for the current analysis. This classification is also consistent with evidence showing that consistent condom use is necessary to most effectively prevent HIV transmission among HIV serodiscordant heterosexual couples (De Vincenzi, 1994).

2.3. Independent variables We examined several sociodemographic characteristics, drug-use behaviors, partner characteristics, relationship- and social-level factors as correlates of consistent condom use with a main partner. Sociodemographic characteristics included age, race/ethnicity, homelessness and history of incarceration. Drug-use behaviors included type of injection drug used, injection frequency, and injecting with a previously used needle. Main partner relationship characteristics included length of relationship (dichotomized at the median), partner age in relation to participant, pregnancy intentions, injection history and needle sharing with the participant. For analyses among men with multiple partners, we also examined total number of sex partners, condom use with non-main female partners and receiving sex for money or drugs. In addition, type of sexual activity with both main and multiple partners was characterized as vaginal sex only versus anal (with or without vaginal) sex. The recall period

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for items assessing sexual and injection risk behaviors was the 3 months preceding baseline interview, unless stated otherwise. Two different scales assessed male IDUs self-efficacy for condom use and attitudes toward condoms. Self-efficacy for condom use with a main partner was measured using a nine-item scale that assessed participants’ ability to use condoms with their main partner under a variety of supportive and non-supportive circumstances; a higher score indicated greater self-efficacy for condom use (Cronbach’s α = 0.95). Participant attitudes toward condom use during sex (e.g., condoms ruin the mood, sex with condoms does not feel as good) were measured using a four-item, “hedonistic outcome expectancies scale”; a higher score indicated more positive attitudes toward condom use (Cronbach’s α = 0.91). Two relationship-level characteristics, condom-use outcome expectancies and intimate partner violence were asked in reference to main partners only. Condom use outcome expectancies, an eight-item scale, assessed anticipated partner reactions (e.g., one’s partner would be mad, supportive, distrustful, etc.) in response to requests for condom use; a higher score indicated a more favorable anticipated response to condom use (Cronbach’s α = 0.84). Intimate partner violence (IPV) was measured by two subscales of the Conflict Tactics Scale (CTS), one measuring perpetration of physical or sexual violence (Cronbach’s α = 0.83) and the other measuring experiences of physical or sexual violence (Cronbach’s α = 0.83) with main partners. Given our focus on men, who may be likely to either underreport perpetrating violence or over-report victimization as a means of justifying their perpetration of IPV, we initially examined IPV separately for perpetration and victimization. However, due to sample size limitations, specifically that few men reported being victimized, we examined IPV dichotomized as any experience with IPV (perpetration or victimization) versus no experience of IPV. Partner and peer norms about condom use were examined with two similar, but separate, sets of items assessing normative beliefs about condom use. These norms were measured by asking men to report (1) whether their partners/peers supported condom use and (2) whether they felt motivated to comply to their partner/peers’ norms (Jamner et al., 1998). A composite variable was constructed by taking the product of these two items. Higher scores indicated more supportive norms for condom use.

2.4. Statistical analysis Formal tests of bivariate associations between independent variables and consistent condom use with main partners were examined separately for the two groups – men who had an exclusive main partner and those who reported multiple partners – using χ2 and t-tests, as appropriate. Separate multivariate logistic regression models were constructed to estimate the odds of consistent condom use with a main partner for each partnership type. Regression models were constructed by incorporating variables found to be significant at the p < 0.05 level in bivariate analyses. Those variables were entered into separate models that included individual level factors, partner- and relationship-level characteristics, and the peer-level construct. Once significant factors in each of these domains were identified, they were entered simultaneously to determine a best-fit model that included only those factors found to be significant at the p < 0.05 level. Model fit was assessed using the −2 log likelihood statistic.

3. Results Overall, the median age was 24 years (IQR = 18–30), which was similar for both groups (Table 1). Men with an exclusive female partner were significantly more likely to be white (73% versus 60%) and to report regular or part-time employment (52% versus 44%) compared to men with multiple female sex partners. Men with multiple partners were more likely to have at least a high school education (43% versus 33%) and to report being homeless in the 6 months preceding baseline interview (41% versus 35%) compared to men with an exclusive partner. Regarding drug-use behaviors, men with multiple sex partners were more likely to report daily alcohol use (14% versus 7%) and

injecting other/polydrugs (17% versus 8%) compared to men with an exclusive sex partner. Men with multiple partners were more likely to report injecting drugs most often with non-sex partners (54% versus 43%), and men with an exclusive partner were more likely to report injection with 1–3 other IDUs (47% versus 40%). No significant differences were observed between groups in injection frequency or injection with a needle that had been previously used by someone else. Consistent condom use with a main partner was reported by 12% (53/429) of men with an exclusive main female partner and by 17% (151/862) of men with multiple female partners (p = 0.009). Overall, the median relationship duration with a main partner was 20 months, which was similar in both groups of men. With regard to sexual activity, men with an exclusive female partner were less likely to engage in anal (with or without vaginal) sex compared to men with multiple partners (26% versus 50%, p < 0.001). Among males with multiple partners, the median number of sex partners during the past 3 months was 4 (IQR = 2–6). In bivariate analyses, across both partnership patterns, consistent condom use with a main partner was reported often among participants who had only vaginal sex, high condom use outcome expectancies, greater ability to use condoms with a main partner, positive hedonistic outcome expectancies and supportive peer and partner norms about condom use (Table 2). Men with an exclusive female partner who was younger or of the same age as the participant were more likely to report consistent condom use with that partner than participants with older partners. For both groups, men who reported injecting three or more times per day were less likely to report consistent condom use with their main partner. In addition, across both groups, men who reported having a main sex partner with whom they injected, that expressed pregnancy intentions, injected drugs, shared needles or experienced IPV were less likely to report consistent condom use with that main partner. Among men with an exclusive female partner, in multivariate analysis, consistent condom use was positively associated with positive outcome expectancies from their main partner following requests for condom use (AOR = 4.26; 95% CI = 1.81–10.07) and supportive partner norms regarding condom use (AOR = 4.75; 95% CI = 1.95–11.56) (Table 3). Men who shared needles with their main partner (AOR = 0.20; 95% CI = 0.07–0.56) or whose main partner expressed pregnancy intentions (AOR = 0.11; 95% CI = 0.02–0.50) were less likely to use condoms consistently with their main sex partner. Among men with multiple partners, in multivariate analysis, consistent condom use with their main female partner was associated with positive outcome expectancies from that partner following requests for condom use (AOR = 1.93; 95% CI = 1.25–2.95), supportive partner norms regarding condom use (AOR = 2.99; 95% CI = 1.82–4.90), positive personal attitudes toward condom use (AOR = 1.83; 95% CI = 1.09–3.06), and recently giving money/drugs for sex (AOR = 2.05; 95% CI = 1.03–4.11). Men who reported injecting drugs with a used needle (AOR = 0.61; 95% CI = 0.40–0.95), experienced IPV with a main partner (AOR = 0.57; 95% CI = 0.37–0.86), and had a partner who expressed pregnancy intentions (AOR = 0.31; 95%

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Table 1 Demographics, drug use and sexual behaviors by partnership patterns among 1291 young male IDUs who had a main, female sex partner, the CIDUS III/DUIT Study, 2002–2004 Variable

Total (n = 1291)

Exclusive main female partner (n = 429)

Multiple female partners (n = 862)

p-Valuea

Recruitment city Baltimore Chicago Los Angeles New York Seattle

30% (390) 28% (361) 13% (171) 13% (165) 16% (204)

25% (108) 39% (167) 13% (57) 7% (29) 16% (68)

33% (282) 23% (194) 13% (114) 16% (136) 16% (136)

<0.001

Age (years) median (IQR)

24 (18–30)

24 (19–29)

24 (18–30)

0.281

Race/ethnicity Hispanic/Latino African American White Other

18% (235) 8% (96) 64% (84) 10% (508)

15% (65) 4% (16) 73% (308) 8% (32)

20% (170) 9% (80) 60% (513) 11% (95)

<0.001

Education (≥HS)

39% (508)

33% (141)

43% (367)

<0.001

Source of most income during past 6 months Regular or part time work Other legal activities Illegal activities

47% (599) 34% (431) 20% (254)

52% (224) 29% (125) 19% (80)

44% (375) 36% (306) 20% (174)

0.015

Homeless during past 6 months (yes) Ever incarcerated (yes)

39% (496) 83% (1070)

35% (148) 82% (350)

41% (348) 84% (720)

0.041 0.383

Alcohol consumption Never Less than daily Daily

17% (224) 71% (916) 12% (148)

20% (87) 73% (313) 7% (28)

16% (137) 70% (603) 14% (120)

<0.001

Drug injected most frequently in last 3 months Heroin only Crack/cocaine/amphetamines only Other/polydrug use

75% (935) 12% (147) 14% (170)

84% (353) 9% (36) 8% (33)

70% (582) 13% (111) 17% (137)

<0.001

Injection frequency (≥3 times per day)

63% (807)

65% (279)

61% (528)

0.186

Number of people injected with 0 1–3 4 or more

17% (213) 42% (544) 41% (534)

15% (62) 47% (202) 39% (165)

18% (151) 40% (342) 43% (369)

0.036

Injected drugs with a used needle (yes)

42% (525)

39% (165)

43% (360)

0.162

Inject most often with No one else Sex partner Other (shooting partner, acquaintance, etc.)

17% (224) 32% (416) 50% (651)

15% (66) 41% (177) 43% (186)

18% (158) 28% (239) 54% (465)

<0.001

Consistent condom use with a main partner Relationship duration with main partner (≥20 months)

16% (204) 51% (659)

12% (53) 52% (222)

17% (151) 51% (437)

0.009 0.722

Type of sexual activity with main partner Vaginal sex only Anal (with or without vaginal) sex

58% (750) 42% (541)

74% (316) 26% (113)

50% (434) 50% (428)

<0.001

Number of sex partners in last 3 months, median (IQR) a

From

␹2

–

1

4 (2–6)

NA

test IQR, interquartile range; ≥HS, at least a high school degree. Data within cells do not always sum to column total due to missing data.

CI = 0.16–0.58) were less likely to report consistent condom use with their main sex partner. 4. Discussion Findings from this study indicate that young, heterosexually active, male IDUs in exclusive or multiple-partner relationships engaged in unprotected sexual activity that place them and their

main female sex partners at risk for HIV and other sexually transmitted infections. We found that consistent condom use among men in monogamous relationships was low, 13%, but similar to prior reports among IDU samples (Kwiatkowski et al., 1999; Booth et al., 2000; Tyndall et al., 2002). Two-thirds of the men in this study had sexual relationships with women other than their main partner; yet only 17% of these individuals reported consistent condom use with their main partners. Moreover, among

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Table 2 Associations between sexual, relationship and drug use characteristics and condom use with a main female partner by partnership patterns among 1291 young male IDUs, the CIDUS III/DUIT Study, 2002–2004 Variable

Relationship duration with main partner (≥20 months) Type of sexual activity with main partner Vaginal sex only Anal (with or without vaginal) sex Age of main partner Younger Older Same age Main partner wants to get pregnant (yes) Main partner injects drugs (yes) Share needles with main partner (yes) Main partner’s reaction to request for condom use (positive) Ability to use condoms with main partner (high) Experience of IPV with main partner (yes) Partner norms regarding condom use Support Oppose Neutral Personal attitudes toward condom use (positive) Peer norms regarding condom use Support Oppose Neutral Gave money/drug for sex in last 3 months (yes) Number of sex partners in last 3 months (>4) Condom use with non-main partners Consistent use Inconsistent use

Men with an exclusive main female partner Inconsistent condom use (n = 376)

Consistent condom use (n = 53)

52% (197)

48% (25)

72% (269) 28% (107)

p-Valuea

Men with multiple female partners p-Valuea

Inconsistent condom use (n = 711)

Consistent condom use (n = 151)

0.476

52% (371)

44% (66)

0.059

89% (47) 11% (6)

0.008

49% (348) 51% (363)

57% (86) 43% (65)

0.074

59% (218) 30% (111) 12% (43)

64% (34) 15% (8) 21% (11)

0.031

54% (378) 34% (238) 13% (91)

49% (74) 33% (49) 19% (28)

0.182

31% (117) 60% (224) 44% (165) 37% (139)

4% (2) 35% (18) 12% (6) 81% (43)

<0.001 <0.001 <0.001 <0.001

32% (224) 46% (321) 31% (217) 30% (212)

12% (18) 34% (51) 17% (25) 62% (93)

<0.001 0.011 0.001 <0.001

57% (213)

87% (46)

<0.001

51% (365)

72% (109)

<0.001

52% (196)

25% (13)

<0.001

56% (395)

34% (52)

<0.000

16% (59) 54% (197) 30% (112)

79% (41) 6% (3) 15% (8)

<0.001

29% (202) 38% (266) 33% (233)

74% (112) 7% (11) 19% (28)

<0.001

8% (31)

36% (19)

<0.001

10% (68)

28% (42)

<0.001

27% (95) 35% (127) 38% (137)

67% (34) 8% (4) 26% (13)

<0.001

39% (269) 29% (203) 32% (222)

63% (94) 13% (20) 24% (35)

<0.001

–

–

–

8% (59)

12% (18)

0.156

–

–

–

35% (248)

38% (58)

0.410

–

–

–

8% (55) 92% (656)

42% (63) 58% (88)

<0.001

Injected drugs with a used needle (yes) Injection frequency (≥3 times per day)

40% (149) 67% (252)

31% (16) 51% (27)

0.222 0.022

46% (316) 63% (449)

30% (44) 52% (79)

<0.001 0.013

Inject most often with Sex partner Other (shooting partner, acquaintance, etc.)

53% (170) 47% (151)

17% (7) 83% (35)

<0.001

37% (215) 63% (367)

20% (24) 80% (98)

<0.001

a

From χ2 test and Fisher’s exact test (when cell n < 5) IPV, intimate partner violence.

men with multiple partners who reported inconsistent condom use with main partners, only 8% reported consistent condom use with their non-main partners, suggesting that the potential for these men to acquire infections and then transmit them to their main partner is high. As these men appeared to be in longterm relationships with their main partners, the high degree of unprotected sex may be related to the difficulties in introducing condoms after a period of no or inconsistent use. This analysis is unique in that it examined differences in condom use by male IDUs in heterosexual relationships with main partners among those in monogamous relationships versus those

with multiple female partners. Prior studies have explored differences in condom use by partner type but have focused their comparisons between main and casual partners, by number of sex partners or to men who have sex with men or sex with both men and women (Booth et al., 2000; Corby and Wolitski, 1996; Falck et al., 1997; Rietmeijer et al., 1998; Semaan et al., 2002). These studies, while important to our understanding of the HIV epidemic, have not specifically assessed the risk profile of IDU males and their primary female partners, who are at increased risk for both HIV acquisition and transmission. By examining condom use across partnership types, our findings indicate that

F. Kapadia et al. / Drug and Alcohol Dependence 91S (2007) S56–S63 Table 3 Adjusted odds ratios for consistent condom use with main female partners among young male IDUs who had an exclusive female main sex partner and among those who had multiple female sex partners, the CIDUS III/DUIT Study, 2002–2004 Variable Model 1: men with an exclusive main female partner Main partner’s reaction to request for condom use (positive) Partner norms regarding condom use Neutral attitude toward condom use Supports condom use Opposes condom use Share needles with partner (yes) Partner wants to get pregnant (yes) Model 2: men with multiple female partners Main partner’s reaction to request for condom use (positive) Partner norm regarding condom use Neutral attitude toward condom use Supports condom use Opposes condom use Personal attitudes toward condom use (positive) Gave money/drug for sex during past 3 months (yes) Injected drugs with a used needle (yes) Experience of IPV with main partner (Yes) Partner wants to get pregnant (yes)

AOR (95% CI) 4.26 (1.81–10.07)

Referent 4.75 (1.95–11.56) 0.14 (0.03–0.70) 0.20 (0.07–0.56) 0.11 (0.02–0.50)

1.93 (1.25–2.95)

Referent 2.99 (1.82–4.90) 0.33 (0.16–0.68) 1.83 (1.09–3.06) 2.05 (1.03–4.11) 0.61 (0.40–0.95) 0.57 (0.37–0.86) 0.31 (0.16–0.58)

AOR, adjusted odds ratio; adjusted for all other variables in the model.

there are differences in factors associated with condom use with a main partner across partnership patterns. This information can inform the development of interventions with HIV-negative men to reduce men’s sexual HIV transmission risk behavior. Such interventions are critically needed, as existing individually based interventions have shown limited effectiveness (van Empelen et al., 2003) or targeted only women, who are often not in control of sexual HIV risk reduction practices (Ickovics and Yoshikawa, 1998; Latka, 2003; Logan et al., 2002; Mize et al., 2002). Consistent with previous reports, factors such as partners’ pregnancy intentions, positive condom use outcome expectancies and supportive partner norms were associated with consistent condom use with main female partners among men in both exclusive and multiple heterosexual partnerships (Cabral et al., 2001; DiIorio et al., 1997). First, pregnancy intentions complicate HIV prevention efforts because individuals who are in monogamous relationships make a conscious and valid decision to not use condoms. However, these intentions need to be balanced against the increased risk of HIV transmission to their main female partner when male IDUs report unprotected sexual activity with multiple partners or sharing syringes with other IDUs. Second, men who indicated that their main partner reacted positively to requests for condom use and were supportive of condom use were also more likely to have protected sex with that partner. Among men in exclusive relationships, those who shared needles with their main female partners were less likely to use condoms consistently with those partners. Prior reports indicate that within main sexual partnerships, sharing drugs and injection equipment is associated with issues of trust and pooling money

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to purchase drugs (Johnson et al., 2002; Unger et al., 2006). Sharing drug injection equipment with a main sex partner can often indicate a significant bond within that sexual relationship; thus, proposing condom use with a main, intimate sex partner may be challenging (Sherman and Latkin, 2001). In addition, gender dynamics influence behavior around condom use and needle sharing; specifically, females are often dependent on their male partners to inject them and male partners are often in control of condom use (Johnson et al., 2002; Unger et al., 2006); as such further research with respect to these issues is warranted. However, given that over 80% of men in this study reported injecting with at least one other person, HIV prevention efforts targeting sexual relationships must address both sexual and injection risk behaviors in order to reduce the risk of both direct and indirect HIV transmission. Consistent condom use among men with multiple partners was also associated with personal attitudes toward the use of condoms (specifically whether men felt condoms reduced sexual pleasure), experiences of IPV, unsafe IDU practices and giving money/drugs for sex. Prior studies have noted that positive attitudes about condoms are associated with increased likelihood of condom use with casual partners (Bogart et al., 2005). We found a significant association between personal attitudes and condom use in main partnerships among men with multiple partners. This suggests that for men who have multiple partners, their attitudes toward condoms and desire for sexual pleasure were as equally important correlates of condom use as partner norms and reactions toward requests for condom use, pregnancy intentions and experiences of IPV. Male IDUs with multiple partners who reported IPV in their main relationship, either as perpetrators or victims, were less likely to report condom use with their main female partner. Similarly, a recent study noted that drug-using men in methadone maintenance programs who experienced IPV were more likely to have multiple sex partners and have unprotected sex (El-Bassel et al., 2001). Our finding that sharing syringes was associated with inconsistent condom use among IDUs reporting multiple partners is consistent with previous findings (Somlai et al., 2003; Booth et al., 1993). In particular, Somlai et al. (2003) noted that syringe sharing, especially with sex partners, was associated with inconsistent condom use during anal intercourse and with having multiple sex partners. Finally, the association between consistent condom use with a main partner among men who gave money or drugs in exchange for sex can be attributed to either self-protection or altruism. Men with multiple or sex-trade partners may, in some instances, perceive their main female partners to also be engaging in sex outside of the main partnership and therefore use condoms as a way to protect themselves. Alternatively, men with multiple, sex-trade partners may feel a greater responsibility for protecting their main partner and are able to balance the desire for intimacy with their perceived responsibility to protect. In a study by Bowen et al. (2006), condom use by heterosexual male crack users was related to both personal responsibility and relationship intimacy such that condom use intentions increased with increasing relationship intimacy. Since these motivations were not assessed in our study, further research in this area is indicated.

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Our study was limited by the fact that it was a cross-sectional analysis, which cannot establish temporality between our main outcome variable and significant correlates. Several potential confounding factors, such as marital status, cohabitation, emotional or financial interdependence, were not available for our analysis and should be assessed in future studies. Socially desirable response bias (Latkin et al., 1993) is an issue when collecting self-reported data on HIV risk behaviors and condom use due to the potential for underreporting risky sexual behaviors and overreporting safer sex behaviors. However, interviews were conducted using audio computer-assisted self-interviewing technology, which has been shown to reduce this bias (Macalino et al., 2002). Injection drug use and sex are the two leading risk factors for HIV transmission. To date, the majority of HIV prevention interventions for IDUs have focused on changing injectionrelated behavior at the individual-level and, to a lesser extent, on reducing risky sexual behaviors. While a considerable body of literature exists on sexual risk-taking among female IDUs, less is known about sexual risk-taking among male IDUs with their female partners (Latka, 2003; Nyamathi et al., 1995; Miller et al., 2002). Our findings indicate that there is a need for more in-depth research focusing on the nexus of sexual and injection risk-taking among male IDUs. In addition, more nuanced considerations of men’s risk-taking behaviors, which extends from personal factors to partner-level and social-level factors, is warranted. Understanding how these factors may be intervened upon given the gender roles that men, especially young, marginalized IDUs, operate within, is necessary for developing HIV interventions that effectively reduce unsafe injection and sexual practices. Not only will such interventions directly protect male IDUs from acquiring HIV, they will also reduce the risk of HIV transmission from infected IDUs to their uninfected sex partners.

directly by the five funded sites in Baltimore, Chicago, Los Angeles, New York City, and Seattle. Acknowledgements

All authors contributed to the design of the study. Dr. Farzana Kapadia directed the analyses and wrote the first draft of the manuscript. All authors contributed to and approved the final manuscript.

The authors thank Brigette Finkelstein-Ulin and Linda Moyer (CDC, Division of Viral Hepatitis) for their contribution to the development of the hepatitis educational materials and incorporation of hepatitis information into the study’s pre/post-test counseling protocols. The authors wish to thank the members of Community/Peer Advisory Boards and HIV Program Review Panels at each site for providing constructive feedback on the intervention and trial designs, and the study staff for their commitment to the success of this project. The DUIT Study Group includes the following people: Steffanie Strathdee, Elizabeth Golub, Marie Bailey-Kloch, Karen Yen-Hobelman (Baltimore); Lawrence Ouellet, Susan Bailey, Joyce Fitzgerald (Chicago); Sharon Hudson, Peter Kerndt, Karla Wagner (Los Angeles); Mary Latka, David Vlahov, Farzana Kapadia (New York); Holly Hagan, Hanne Thiede, Nadine Snyder, Jennifer V. Campbell (Seattle); Richard Garfein, David Purcell, Ian Williams, Paige Ingram, Andrea Swartzendruber (CDC). The authors also acknowledge the following people for their contributions to this research: Yvette Bowser, Peter O’Driscoll, Janet Reeves, Marcella Sapun (Baltimore); Angus Atkins-Trimnell, Mary Bonilla, David Cosey, Jaime Delgado, Julio Garcia, Michelle Giles, Erin Kubalanza, Michael Phillips, Edward Snulligan (Chicago); Marrisa Axelrod, Elizabeth Faber, Lawrence Fernandez Jr., Christian Geannette, Roberto Rojas (Los Angeles); Ebele Benjamin, Sebastian Bonner, Micaela Coady, Joanna Cruz, Sandra DelVecchio, Dirk Jackson, Gregory Malave, Joan Monserrate, Danielle Ompad, Clarisse Miller O’Shea, Yingfeng Wu, Manny Yonko (New York); Stanley Brown, Rong Lee, Susan Nelson, Jef St. De Lore, Carrie Shriver, Jeanette Frazier, Jean Pass, Paul Swenson (Seattle); Yuko Mizuno, Janet Moore, Ann O’Leary, Vincent Raimondi, Scott Santibanez, Roberto Valverde (CDC); Wendi Kuhnert, Himal Dhotre, Leigh Farrington, (CDC Division of Viral Hepatitis); Suzette Bartley, Dollene Hemmerlein (CDC Serum Bank Branch).

Conflict of Interest

References

Authorship

There are no conflicts of interest to report by any of the authors. Role of the Funding Source This study was funded in its entirety by a cooperative agreement from the Centers for Disease Control and Prevention (CDC), U64/CCU317662, U64/CCU517656, U64/CCU917655, U64 CCU217659, U64/CCU017615. Scientists from CDC were involved in all aspects of study design, centralized data management, interpretation of the data, and preparation of the manuscript for publication. The CDC was not directly involved in data collection, which was conducted

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