Disparities in the Patterns and Determinants of HIV Risk Behaviors among Adolescents Entering Substance Abuse Treatment Programs

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Disparities in the Patterns and Determinants of HIV Risk Behaviors among Adolescents Entering Substance Abuse Treatment Programs Mesfin S. Mulatu, PhD, MPH; Kimberly Jeffries Leonard, PhD; Dionne C. Godette, PhD; and Darren Fulmore, PhD Financial support: Preparation of this paper was partially supported by the Center for Substance Abuse Treatment (CSAT) contract #270-2003-00006. We are also grateful to all CSAT grantees who collected the original data and to Dr. Michael Dennis, Rod Funk and Melissa Ives at Chestnut Health Systems for their support with the pooled clinical data. Opinions expressed in this paper are those of the authors and do not represent official positions of the government, the grantees or the individuals above. Background: Black youth are disproportionately affected by the HIV/AIDS epidemic. This study examined disparities in patterns and determinants of sexual risk behaviors among black and white adolescents in substance abuse treatment programs. Methods: We used pooled clinical data collected from 4,565 sexually active 12–17-year-old black (29.7%) and white (70.3%) adolescents entering outpatient and residential substance abuse treatment programs nationally. Multivariate logistic regression analyses were used to examine racial differences in patterns of sexual risk behaviors and the associations of these behaviors with demographic, socioenvironmental and psychosocial risk factors, including substance use and abuse, symptoms of mental disorders and criminal behaviors. Results: Blacks were significantly more likely than whites to have had sex with multiple partners, purchased or traded sex and used substances to enhance their sexual experiences, even after adjusting for demographic, socioenvironmental and psychosocial risk factors. Substance use and abuse, internalizing symptoms and drug-related crimes were significantly associated with engaging in ≥2 sexual risk behaviors in both groups. Disparities in determinants of HIV risk were also found. For instance, male gender, single-parent custody and history of criminal justice involvement were associated with having had sex with multiple partners among blacks but not among whites. Demographic, socioenvironmental and psychosocial risk factors accounted for up to 30% of the variance in sexual risk in both groups. Conclusions: Black adolescents with substance use problems are at greater risk for HIV infection than their white peers because of their higher rates of sexual risk behaviors.

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Differences in co-occurring psychosocial problems did not fully explain racial disparities in sexual risk behaviors. HIV prevention programs for black adolescents in treatment should consider both individual and broader contextual factors that co-occur with sexual risk behaviors. Key words: HIV/AIDS n risk behaviors n children/ adolescents n African Americans n substance abuse n treatment n health disparities © 2008. From the Center for Community Prevention and Treatment Research, The MayaTech Corp., Atlanta, GA (Mulatu); Center for Technical Assistance, Training and Research Support, The MayaTech Corp., Silver Spring, MD (Leonard, Fulmore); and Department of Health Promotion and Behavior, College of Public Health, University of Georgia, Athens, GA (Godette). Send correspondence and reprint requests for J Natl Med Assoc. 2008;100:1405–1416 to: Dr. Mesfin S. Mulatu, Center for Community Prevention and Treatment Research, The MayaTech Corp., 2751 Buford Highway NE, Suite 202, Atlanta, GA 30324; phone: (404) 264-2644, fax: (404) 264-2641; e-mail: [email protected]

Introduction

M

itigating the spread of HIV/AIDS has been on the United States’ health agenda since the early 1980s,1,2 and several prevention and treatment efforts have helped reduce infection rates among some high-risk groups [e.g., white males who have sex with other males (MSM)], decrease motherto-child transmissions, improve the lives of those with AIDS, and reduce AIDS-related morbidity and mortality.3,4 Despite these achievements, blacks in general and young people continue to be disproportionately affected by the epidemic.3 For instance, between 2001 and 2004, approximately 51% of all new HIV/AIDS diagnoses were among blacks, who represent about 13% of the U.S. population.4 Among youth, AIDS rates are highest among young blacks (63 per 100,000) compared to whites (3 per 100,000).5 As we might expect, AIDS prevalence rates are particularly higher among those aged 20–44 than among other age groups for all racial groups.3 The median time between HIV infection and development of opportunistic infections associated with AIDS is approximately 10 years6,7 and, therefore, the VOL. 100, NO. 12, DECEMBER 2008 1405

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majority of young adults with AIDS are likely to have been infected during their adolescent years. As a result, adolescence is an important period in the lifespan for understanding the epidemiology of HIV/AIDS and to implementing prevention programs. Adolescence (ages 12–17 years) is a time when people often initiate behaviors that put them at risk for positive or negative health and social outcomes later in life.8 It is a period of considerable physical, social, psychological and cognitive transitions replete with behavioral experimentation.8,9 This behavioral experimentation often involves risk-taking, which is a normal part of adolescent development.9 Evidence from prior studies indicates that adolescent risk behaviors tend to occur either serially and in short succession10 or cluster together.11,12 Sexual activity and alcohol and other drug (AOD) use are among the most prevalent co-occurring risk behaviors, both of which are often initiated during adolescence. Adolescent AOD use and sexual risk behaviors, along with other risk behaviors and risk contexts, have been associated with the experience of substantial social problems, morbidity and mortality during adolescence13 and later in life.14,15 A review of epidemiological studies indicates that black adolescents tend to have poorer health outcomes compared to other racial groups, with the exception of native Americans,16 including higher rates of HIV infections and other sexually transmitted infections (STIs). Recent investigations suggest that the HIV risk that blacks experience cannot be accounted for by only examining use of injection drugs17 or heavy engagement in high-risk behaviors because black adolescents tend to be at high-risk relative to whites even when their behaviors are normative.18 Furthermore, injection drug use is rare among adolescents; as a result, adolescents are more likely to become infected with HIV through noninjection drug use behaviors or risky sexual activity.17 Adolescents seeking treatment for AOD use disorders are among those at highest risk for poor health outcomes. Factors associated with increased risk of HIV infection among this population compared to non-AOD users include: earlier age of first intercourse, inconsistent condom use, poorer HIV-related knowledge, lower perceived susceptibility to HIV infection, higher levels of psychopathology, more permissive attitudes towards sex and lower self-efficacy to engage in preventive behaviors.19 Although adolescents in AOD use treatment are at high risk for HIV risk behaviors and subsequent infection, they are a relatively understudied population as it relates to HIV. The few studies that have examined HIV risk among adolescent treatment populations have focused primarily on HIV knowledge, attitudes and engaging in multiple HIV risk behaviors20-22 or the relationship that impulsivity and risk-taking propensity have to HIV.19,23 Research on racial differences in factors associated with HIV risk behavior or in the prevalence of 1406 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

HIV risk behaviors among adolescents within an AOD treatment setting is limited. The goal of this study was to examine whether there were differences in HIV risk behaviors and factors associated with engaging in HIV risk behaviors between black and white adolescents in an AOD treatment population. We examined the relationship that socioenvironmental factors, substance use and abuse, symptoms of mental disorders and criminal behaviors had with HIV risk behaviors. We sought to answer the following overarching questions: Do black adolescents differ from whites on HIV risk behaviors? What are the odds of black adolescents engaging in HIV risk behaviors relative to those of white adolescents? And, are there differences between black and white adolescents in the association between HIV risk behaviors with socioenvironmental risk factors, substance use and abuse, symptoms of mental disorders and criminal behaviors? In addition to providing some insight regarding the factors associated with the spread of HIV among black youth, the findings of this study are expected to help substance abuse treatment providers better tailor HIV interventions programs to address the unique needs and vulnerabilities of black and white adolescents with substance abuse problems.

Methods Sample The sample for this study was derived from pooled clinical data collected between 1998 and 2006 from 12– 17-year-old adolescents entering 97 federally funded substance abuse treatment programs across the United States (in 31 states and the District of Columbia). There were 11,623 adolescents in this data set; 21% of these adolescents were enrolled in inpatient residential programs and the remaining were in outpatient programs. For the purposes of this study, only black (n=1,881) and white (n=4,962) adolescents were retained. Of these, 82.4% (n=1,508) of blacks and 73.9% (n=3,601) of whites [c2 (1)=52.74, p<0.001] were sexually active within the past year. Data on specific sexual behaviors were collected on 89.5% (n=1,349) of black and 89.1% (n=3,207) of white adolescents [c2 (1) =0.17, p=0.676]. Thus, our analytical sample consists of all black and white adolescents with data on specific past-year sexual behaviors (n=4,556).

Measures Data used in this study were collected with trained interviewers using the Global Appraisal of Individual Needs (GAIN)—a comprehensive and standardized biopsychosocial assessment developed to apply in both research and clinical settings to support diagnosis, treatment planning and placement, and outcome and economic evaluation.24,25 GAIN’s substance abuse and other psychosocial scales have excellent psychometric propVOL. 100, NO. 12, DECEMBER 2008

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erties; detailed validity and reliability information about GAIN scales has been reported elsewhere.24,25

Sexual Risk Behaviors Adolescents who were sexually active within the past 12 months were asked a series questions with a yes/ no response format. The questions began with a phrase “During the past 12 months, did you …” and inquired whether or not respondents: had sex while they or their partners were high on AOD; had sex involving anal intercourse; traded sex for gifts, money or drugs; purchased sex with gifts, money or drugs; had sex with ≥2 partners; had sex without a condom or any other barrier; experienced a lot of pain during or after sex; used AOD to make sex last longer or hurt less; had sex with injection drug users (IDUs); or had sex with an MSM. Each of these HIV risk behaviors was treated as a dichotomous outcome variable, except in 2 instances where items were combined because of low frequencies. First, we combined sex with MSM and sex with IDU into one item – to create a sex with a high-risk group measure. Second, we combined trading sex for and purchasing sex with gifts, money or drugs into one item—to create a transactional sex measure. In addition, we created another combined sexual risk measure based on the median value of a count of the 8 sexual risk behaviors: low-risk (0–1 behavior) versus high-risk (2–8 behaviors).

Substance Use, Abuse and Problems Measures of substance use and related problems were also included in this study. The Substance Problems Scale (SPS) assesses the counts of 16 symptoms of AOD use disorders (including abuse and dependence) and substance-induced problems (physical and psychological) associated with the use of AOD within the past year. The Substance Frequency Scale (SFS) assesses the average of the percent of days reported of any substance use within the past 90 days. Final scores range from 0– 100. Years of substance use were computed by subtracting age at first use of any substance from the current age of the respondents. In order to examine the potential associations between a specific substance used and HIV risk behaviors, we separately recoded past year use of the most prevalent substances (i.e., alcohol, marijuana, cocaine, opiates and amphetamines) into 2 categories: 0 = not used and 1 = used.

Symptoms of Mental Health Disorders Two broad dimensions of the symptoms of mental disorders were included in this study: internalizing and externalizing symptoms. The Internal Mental Distress Scale (IMDS) assesses the count of 43 symptoms related to internal psychological distress, including somatic stress, homicidal/suicidal thoughts, depression, anxiety and traumatic stress. Each item is scored 0 (absent) or 1 (present), indicating the absence or presence of the JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

symptom, respectively; composite scale scores ranged from 0 to 43. Similarly, the Behavioral Complexity Scale (BCS) is a count of 33 external behavioral problems, including the symptoms of inattentiveness, hyperactivity, impulsivity and conduct disorders. The BCS was scored similarly as the IMDS, and composite score for this scale ranged from 0–33.

Criminal Behaviors Three scales measuring self-reported criminal behaviors committed by respondents within the past year were used. The scales were the: 1) Property Crime Scale (PCS; 7 items), which assessed whether or not crimes such as vandalism, theft, and breaking and entering were committed; 2) Interpersonal Crime Scale (ICS; 6 items), which assessed crimes against people, including the use of force to get money, assault and murder; and 3) Drug Crime Scale (DCS; 4 items), which assessed crimes such as driving while under the influence of substances, distribution or sale of drugs, or gang membership. A seventh item of ICS (i.e., sexual assault) and a fifth item of DCS (i.e., trading sex for drugs) were deleted to avoid confounding with outcome variables. Each scale’s items were scored as 0 (absent) or 1 (present).

Social Environmental Risk Factors We used 5 variables as indicators of the social and environmental risk context of the adolescents: 1) singleparent custody, 2) history of being homeless or runaway, 3) history of victimization, 4) history of criminal justice involvement, and 5) family history of substance abuse. Each of these items was coded 0 (absent) or 1 (present).

Demographic Characteristics Five demographic characteristics were also included in the analyses and coded as follows: age in years (ranging from 12–17), gender (1 = male, 2 = female), selfreported race (1 = white, 2 = black), educational attainment in years of education completed (range 5–12 years) and region of residence (1 = south, 2 = midwest, 3 = west and 4 = northeast).

Data Analyses We conducted 3 sets of analyses in this study. First, we conducted bivariate analyses, using the Chi-squared test for proportions and 1-way analysis of variance (ANOVA), to examine the patterns of similarities and differences in sexual risk behaviors, substance use and abuse, symptoms of mental disorders, criminal behaviors, socioenvironmental risk and demographic characteristics between black and white adolescents. Second, we estimated 9 multivariate logistic regression models in which each of the specific sexual risk behaviors and the new combined risk measure served as dependent variables and race served as the independent variable. In each of these models, we also adjusted for demoVOL. 100, NO. 12, DECEMBER 2008 1407

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graphic characteristics, socioenvironmental risk factors, substance use and abuse, symptoms of mental disorders, and criminal behaviors. These analyses allowed us to examine the likelihood of black adolescents engaging in each of the sexual risk behaviors before and after adjusting for potential risk factors. Third, to examine racial disparities in determinants of sexual risk behaviors, we re-estimated the above models for blacks and whites separately. In these models, the dependent variables were sexual risk behaviors and the independent variables were demographic characteristics, socioenvironmental risk factors, substance use and abuse, symptoms of mental disorders and criminal behaviors.

Results Disparities in Socioenvironmental Risk, Substance Use and Abuse, and Psychosocial Problems

We applied the Chi-squared test for proportions to examine racial differences in dichotomous variables, including gender, region, socioenvironmental risk factors and past year use of specific drugs. Oneway ANOVA was used to determine mean differences in continuous variables, including age, education, substance use frequency and problems, symptoms of mental disorders and counts of criminal behaviors. As shown in Table 1, the comparisons revealed that black adolescents had lower levels of substance use and associated problems, symptoms of mental disorders, and property crimes than whites. In addition, black adolescents were

Table 1. Demographic, socioenvironmental risk, substance use and abuse, symptoms of mental disorders and criminal behavior profiles of black and white adolescents Black (n=1,349) % Demographic Characteristics Female Age Education Region South Midwest West Northeast Socioenvironmental Risk Factors Family history of substance abuse Single parent custody at admission Ever homeless or runaway Ever victimized Ever involved with criminal justice Substance Use and Abuse Substance use problems (SPS) Substance frequency (SFS) Years of substance use Used alcohol Used marijuana Used cocaine Used opiates Used amphetamines

15.9 36.6

White (n=3,207)

Mean

SD

15.54 8.78

1.17 1.32

% 33.3 31.5

F or χ2

Mean

SD

(df=1)*

p

15.86 9.27

1.05 1.30

142.02 85.45 134.87 11.56

0.000 0.000 0.000 0.001

34.7 11.7 17.0

27.3 27.9 13.3

25.47 141.17 10.01

0.000 0.000 0.002

69.9 63.0 27.5 57.5 88.4

82.6 43.3 35.0 67.6 82.9

86.40 147.51 24.51 42.44 21.41

0.000 0.000 0.000 0.000 0.000

5.56 14.23 2.66

3.94 14.51 2.01

Symptoms of Mental Disorders Internalizing symptoms (IMDS) Externalizing symptoms (BCS)

6.82 8.87

Criminal Behaviors Property crime (PCS) Interpersonal crime (ICS) Drug-related crime (DCS)

1.13 0.98 0.82

66.4 92.1 4.1 4.7 4.0

8.22 14.41 3.20

4.67 15.45 2.13

335.59 0.12 61.87 401.64 0.98 260.99 450.30 284.28

0.000 0.729 0.000 0.000 0.320 0.000 0.000 0.000

7.88 8.19

9.79 12.34

9.37 8.16

104.19 170.85

0.000 0.000

1.64 1.32 1.40

1.49 0.73 0.72

1.90 1.07 1.02

35.80 45.28 8.51

0.000 0.000 0.004

90.6 93.0 24.4 34.9 25.5

* F values are provided for mean comparisons; c2 values are provided for comparisons involving proportions. SD: Standard deviation; df: Degrees of freedom

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also less likely than whites to have a family history of substance abuse, history of homelessness/running away and history of victimization. However, black adolescents were more likely than white adolescents to come from single-parent households and to have had a history of criminal justice involvement. Black adolescents also committed significantly more interpersonal and drugrelated offenses than white adolescents.

Disparities in Prevalence of Sexual Risk Behaviors Overall, 82.6% of black and 81.5% of white adolescents had engaged in ≥1 HIV risk behaviors within the past 12 months [c2 (df=1) = 1.07, p=0.301]. In our black and white combined sample, having sex with ≥2 partners (59.3%), having sex while high on AODs (50.3%), and having sex without a barrier (48.3%) were the 3 most prevalent HIV risk behaviors. Table 2 presents the prevalence of specific sexual risk behaviors by race, and the results of logistic regression analyses estimating the relative odds of blacks compared to whites in engaging in each of these behaviors before and after controlling for demographic characteristics, socioenvironmental risk, substance use and abuse, symptoms of mental disorders and criminal behaviors. Unadjusted comparisons revealed that black adolescents were less likely to have had sex while high on AOD, to have had sex without a

barrier, to have had a lot of pain during or after sex, to have had sex with a high-risk group and to have engaged in ≥2 of these sexual risk behaviors. On the other hand, blacks were more likely than whites to have had sex with ≥2 partners (p<0.001). As shown in the last panel of Table 2, analyses adjusting for demographic, socioenvironmental and psychosocial risk factors revealed that blacks were ≥2 times more likely than whites to have had sex with ≥2 partners; to have traded sex for or purchased sex with AOD, money, or gifts; and to have used AOD to enhance sexual experience. On the combined risk measure, blacks were also 21% more likely than whites to have engaged in ≥2 sexual risk behaviors. While race was a significant factor in these multivariate analyses, it accounted for a very small amount (no more than 5%) of the variation in HIV risk behaviors.

Disparities in Determinants of Sexual Risk Behaviors Separate multivariate logistic regressions for blacks and whites were estimated to examine the similarities and differences in the degree of relationships between the demographic and psychosocial factors and each of the specific HIV risk behaviors and the combined sexual risk measure. Differences and similarities between blacks and whites in factors associated with each sexual risk measure were found. Below, we present findings for

Table 2. Prevalence of sexual risk behaviors among blacks and whites and unadjusted and adjusted odds of blacks engaging in sexual risk behaviors compared to whites Sexual Risk Behaviors within the Past Year

Black White Unadjusted Odds for (n=1,349) (n=3,207) Blacks Compared to Whites

Adjusted Odds for Blacks Compared to Whites

%

%

OR

95% CI

p

OR

95% CI

p

Had sex while you or your partner was high on AOD

38.2

55.3

0.53

0.46–0.60

0.000

0.87

0.72–1.05

0.097

Had sex involving anal intercourse

6.0

6.9

0.87

0.66–1.15

0.330

1.09

0.77–1.54

0.661

Traded or purchased sex with drugs, gifts or money

2.2

2.7

0.95

0.61–1.46

0.804

3.42

1.83–6.39

0.000

Had sex with ≥2 partners

68.2

55.6

1.71

1.48–1.96

0.000

2.00

1.68–2.38

0.000

Had sex without any kind of condom or other barrier 41.8

51.1

0.69

0.60–0.79

0.000

1.03

0.87–1.22

0.849

Had a lot of pain during or after having had sex

3.5

5.5

0.58

0.41–0.83

0.002

1.27

0.81–1.99

0.273

Used AOD to make sex last longer or hurt less

8.5

8.0

1.13

0.89–1.43

0.332

2.12

1.53–2.94

0.000

Had sex with a high risk partner (MSM or IDU)

1.3

5.0

0.28

0.17–0.47

0.000

0.75

0.43–1.34

0.251

Had ≥2 of the above sexual risk behaviors

50.2

57.8

0.76

0.66–0.87

0.000

1.21

1.01–1.45

0.036

These results are based on 9 separate logistic regression models that compared the likelihood of black adolescents in engaging in each of the sexual risk behaviors compared to while adolescents, before and after controlling for other demographic characteristics, socioenvironmental risk, substance use and abuse, symptoms of mental disorders, and criminal behaviors. OR: odds ratio; CI: Confidence interval

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Table 3. Factors associated with engaging in sex with ≥2 partners in past year among black and white adolescents in substance abuse treatment programs Blacks (n=1,349)

Whites (n=3,207)

OR

95% CI

p

OR

95% CI

p

1.00 0.40 1.08 0.90

– 0.27–0.58 0.91–1.28 0.78–1.04

– 0.000 0.397 0.162

1.00 0.95 1.05 1.00

– 0.79–1.14 0.94–1.18 0.91–1.09

– 0.564 0.372 0.983

1.00 0.93 0.77 1.37

– 0.67–1.29 0.49–1.20 0.91–2.05

– 0.667 0.245 0.130

1.00 0.75 0.80 0.92

– 0.61–0.92 0.65–0.99 0.71–1.18

– 0.006 0.037 0.505

1.00 0.87

– 0.64–1.17

– 0.341

1.00 1.23

– 0.99–1.51

– 0.056

1.00 1.38

– 1.05–1.81

– 0.021

1.00 1.02

– 0.87–1.19

– 0.821

1.00 0.86

– 0.61–1.23

– 0.411

1.00 1.05

– 0.87–1.26

– 0.621

1.00 1.17

– 0.87–1.57

– 0.291

1.00 1.21

– 1.01–1.45

– 0.035

1.00 1.60

– 1.07–2.39

– 0.023

1.00 1.18

– 0.95–1.45

– 0.128

1.02 1.03 1.07

0.98–1.07 1.02–1.04 0.98–1.15

0.320 0.000 0.114

1.01 1.01 1.05

0.99–1.04 1.00–1.02 1.00–1.09

0.276 0.007 0.039

1.00 1.05

– 0.79–1.39

– 0.762

1.00 1.24

– 0.95–1.61

– 0.117

1.00 1.15

– 0.66–2.01

– 0.623

1.00 .85

– 0.63–1.17

– 0.324

1.00 1.24 1.00

– 0.57–2.71 –

– 0.592 –

1.00 1.11 1.00

– 0.89–1.38 –

– 0.339 –

0.71

0.35–1.46

0.353

1.02

0.84­–1.24

0.822

1.00 2.45

– 0.87–6.93

– 0.090

1.00 1.22

– 0.98–1.51

– 0.076

Symptoms of Mental Disorders Internalizing symptoms (IMDS) Externalizing symptoms (BCS)

1.02 1.01

1.00–1.05 0.99–1.03

0.096 0.441

1.00 1.02

0.99–1.01 1.01–1.04

0.742 0.001

Criminal Behaviors Property crime (PCS) Interpersonal crime (ICS) Drug-related crime (DCS)

0.97 0.93 1.39

0.86–1.10 0.79–1.10 1.15–1.68

0.647 0.399 0.001

0.96 1.21 1.17

0.90–1.02 1.08–1.35 1.05–1.31

0.176 0.001 0.005

Sociodemographic Characteristics Gender Male (ref.) Female Age Education Region South (ref.) Midwest West Northeast Socioenvironmental Risk Factors Family History of SA No (ref.) Yes Single Parent Custody No (ref.) Yes Ever Homeless/Runaway No (ref.) Yes Ever Victimized No (ref.) Yes Ever Involved with CJS No (ref.) Yes Substance Use and Abuse Substance Use Problems (SPS) Substance Use Frequency (SFS) Years of Substance Use Used Alcohol No (ref.) Yes Used Marijuana No (ref.) Yes Used Cocaine No (ref.) Yes Used Opiates No (ref.) Yes Used Amphetamines No (ref.) Yes

Separate logistic regression models were estimated for blacks and whites to examine similarities and differences in factors associated with the likelihood of having sex with ≥2 partners. SA: Substance abuse; CJS: Criminal justice system; ref.: Reference category; OR: Odds ratio; CI: Confidence interval

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Table 4. Factors associated with engaging in unprotected sex in the past year among black and white adolescents in substance abuse treatment programs Blacks (n=1,349)

Whites (n=3,207)

OR

95% CI

p

OR

95% CI

p

1.00 1.79 1.15 0.98

– 1.26–2.54 0.98–1.35 0.86–1.13

– 0.001 0.095 0.824

1.00 1.73 1.29 0.99

– 1.44–2.09 1.15–1.44 0.90–1.08

– 0.000 0.000 0.755

1.00 1.22 0.81 1.02

– 0.90–1.64 0.52–1.25 0.70–1.48

– 0.203 0.335 0.916

1.00 1.01 0.90 0.78

– 0.82–1.24 0.72–1.11 0.61–1.01

– 0.945 0.311 0.063

1.00 1.22

– 0.91–1.63

– 0.180

1.00 1.11

– 0.90–1.38

– 0.336

1.00 1.10

– 0.85–1.42

– 0.485

1.00 1.11

– 0.95–1.31

– 0.187

1.00 1.19

– 0.88–1.62

– 0.267

1.00 1.21

– 1.00–1.45

– 0.046

1.00 1.26

– 0.96–1.66

– 0.101

1.00 1.20

– 1.00–1.45

– 0.048

1.00 1.32

– 0.87–2.00

– 0.192

1.00 1.06

– 0.85–1.31

– 0.617

1.03 1.01 1.05

0.99–1.07 1.00–1.02 0.98–1.13

0.170 0.043 0.157

1.01 1.00 1.03

0.99–1.04 1.00–1.01 0.99–1.07

0.269 0.507 0.163

1.00 1.37

– 1.04–1.81

– 0.024

1.00 1.08

– 0.82–1.42

– 0.581

1.00 0.86

– 0.48–1.52

– 0.600

1.00 0.86

– 0.63–1.18

– 0.354

1.00 0.97

– 0.51–1.84

– 0.933

1.00 1.54

– 1.24–1.91

– 0.000

1.00 0.47

– 0.25–0.87

– 0.017

1.00 1.12

– 0.92–1.36

– 0.264

1.00 1.59

– 0.80–3.18

– 0.188

1.00 1.10

– 0.88–­1.36

– 0.406

Symptoms of Mental Disorders Internalizing symptoms (IMDS) Externalizing symptoms (BCS)

1.02 1.00

1.00–1.04 0.98–1.02

0.094 0.972

1.02 1.02

1.01–1.03 1.00–1.03­­

0.003 0.011

Criminal Behaviors Property crime (PCS) Interpersonal crime (ICS) Drug-related crime (DCS)

1.07 0.99 1.17

0.97–1.19 0.86–1.14 1.00–1.37

0.192 0.873 0.045

1.02 1.05 1.09

.96–1.08 .95–1.17 .98–1.22

0.588 0.349 0.127

Sociodemographic Characteristics Gender Male (ref.) Female Age Education Region South (ref.) Midwest West Northeast Socioenvironmental Risk Factors Family History of SA No (ref.) Yes Single Parent Custody No (ref.) Yes Ever Homeless/Runaway No (ref.) Yes Ever Victimized No (ref.) Yes Ever Involved with CJS No (ref.) Yes Substance Use and Abuse Substance Use Problems (SPS) Substance Use Frequency (SFS) Years of Substance Use Used Alcohol No (ref.) Yes Used Marijuana No (ref.) Yes Used Cocaine No (ref.) Yes Used Opiates No (ref.) Yes Used Amphetamines No (ref.) Yes

Separate logistic regression models were estimated for blacks and whites to examine similarities and differences in factors associated with the likelihood of having unprotected sex. SA: Substance abuse; CJS: Criminal justice system; ref.: Reference category; OR: Odds ratio; CI: Confidence interval

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Table 5. Factors associated with engaging in ≥2 sexual risk behaviors in past year among black and white adolescents in substance abuse treatment programs Blacks (n=1,349)

Whites (n=3,207)

OR

95% CI

p

OR

95% CI

p

1.00 1.24 1.09 0.94

– 0.85–1.82 0.92-1.32 0.81-1.09

– 0.264 0.307 0.429

1.00 1.67 1.22 0.97

– 1.37–2.04 1.08–1.38 0.88–1.07

– 0.000 0.002 0.585

1.00 0.97 1.10 1.52

– 0.70-1.34 0.69-1.75 1.03-2.25

– 0.867 0.688 0.037

1.00 0.80 0.77 0.83

– 0.64–1.00 0.61–.97 0.63–1.09

– 0.049 0.029 0.178

1.00 1.34

– 0.99–1.80

– 0.056

1.00 1.30

– 1.04–1.63

– 0.022

1.00 1.25

– 0.95–1.64

– 0.114

1.00 1.02

– 0.86–1.21

– 0.822

1.00 0.95

– 0.68–1.33

– 0.775

1.00 1.22

– 1.00–1.49

– 0.050

1.00 1.29

– 0.97–1.72

– 0.080

1.00 1.20

– 0.99–1.46

– 0.061

1.00 1.99

– 1.28­–3.09

– 0.002

1.00 1.06

– 0.84–1.33

– 0.623

1.08 1.03 1.11

1.03–1.13 1.01–1.04 1.03–1.20

0.001 0.000 0.006

1.06 1.02 1.08

1.04–1.09 1.01–1.02 1.03–1.13

0.000 0.000 0.001

1.00 1.55

– 1.16–2.06

– 0.003

1.00 1.24

– 0.93–1.65

– 0.139

1.00 1.50

– 0.79–2.83

– 0.212

1.00 1.03

– 0.73–1.44

– 0.878

1.00 1.09

– 0.52­–2.28

– 0.814

1.00 1.18

– 0.93–1.51

– 0.170

1.00 0.55

– 0.28–1.08

– 0.082

1.00 1.24

– 1.01–1.53

– 0.041

1.00 1.15

– 0.49–2.68

– 0.748

1.00 1.11

– 0.87–1.41

– 0.399

Symptoms of Mental Disorders Internalizing symptoms [IMDS] Externalizing symptoms [BCS]

1.03 1.00

1.01–1.05 0.98–1.02

0.014 0.858

1.01 1.03

1.00–1.00 1.01–1.04

0.039 0.000

Criminal Behaviors Property crime [PCS] Interpersonal crime [ICS] Drug-related crime [DCS]

1.02 1.00 1.47

0.91–1.15 0.85–1.17 1.23–1.75

0.710 0.990 0.000

0.98 1.11 1.30

0.92–1.05 0.99–1.26 1.15–1.48

0.622 0.085 0.000

Sociodemographic Characteristics Gender Male (ref.) Female Age Education Region South (ref.) Midwest West Northeast Socioenvironmental Risk Factors Family History of SA No (ref.) Yes Single Parent Custody No (ref.) Yes Ever Homeless/Runaway No (ref.) Yes Ever Victimized No (ref.) Yes Ever Involved with CJS No (ref.) Yes Substance Use and Abuse Substance Use Problems [SPS] Substance Use Frequency [SFS] Years of Substance Use Used Alcohol No (ref.) Yes Used Marijuana No (ref.) Yes Used Cocaine No (ref.) Yes Used Opiates No (ref.) Yes Used Amphetamines No (ref.) Yes

Separate logistic regression models were estimated for blacks and whites to examine similarities and differences in factors associated with the likelihood of having ≥2 sexual risk behaviors; SA: Substance abuse; CJS: Criminal justice system; ref.: Reference category; OR: Odds ratio; CI: Confidence interval

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the 2 most-common specific sexual risk behaviors (sex with multiple partners and unprotected sex) and for the combined sexual risk measure. Although the frequency of substance use and involvement in drug-related criminal activities were related to having had sex with ≥2 partners among both blacks and whites, other significant risk factors for this behavior were disparate by race. For blacks, multipartnered sex was associated with being male, being from a single parent household and involvement with the criminal justice system. For whites, being from the south (compared to being from midwest or west), history of victimization, externalizing symptoms and interpersonal criminal behaviors were also associated with having had ≥2 partners. The overall model for this risk behavior was significant for both blacks [χ2 (df=24) = 185.73, p<0.001, Nagelkerke’s R2=0.198] and whites [χ2 (df=24) = 293.86, p<0.001, Nagelkerke’s R2=0.128]. Table 3 presents the findings from this analysis. With the exception of being female, which was associated with unprotected sex in both blacks and whites, significant racial variations were found in the determinants of this sexual risk behavior. Among blacks, unprotected sex was likely among those with high frequency of substance use, those who used alcohol and those with drug-related offenses, but lower among those who used opiates. Among whites, unprotected sex was more likely among older adolescents, those with the history of homelessness/running away and victimization, those who used cocaine and those with higher levels of internalizing and externalizing symptoms. The overall model for this risk behavior was significant for both blacks [χ2 (df=24) = 151.80, p<0.001, Nagelkerke’s R2=0.158) and whites [χ2 (df=24) = 402.47, p<0.001, Nagelkerke’s R2=0.171]. Table 4 presents findings from this analysis. Factors that were associated with the combined sexual risk measure (i.e., engaging in ≥2 sexual risk behaviors) tended to be similar between blacks and whites. Among both groups, higher levels of substance use problems, substance use frequency, internalizing symptoms, drug-related offenses and longer years of substance use were significantly positively associated with the combined sexual risk measure. Among blacks, past year use of alcohol, being from the northeast and history of involvement with the criminal justice system were also significantly associated with engaging in ≥2 sexual risk behaviors. Among whites, family history of substance abuse, history of homelessness/running away, older age, being female, being from the south, past year cocaine use, and externalizing symptoms were additional determinants of engaging in ≥2 sexual risk behaviors. The overall model for this risk behavior was significant for both blacks [c2 (df=24) = 334.53, p<0.001, Nagelkerke’s R2=0.321] and whites [c2 (df=24) = 740.92, p<0.001, Nagelkerke’s R2=0.300]. Table 5 presents findings from this analysis. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

Discussion

This study examined disparities in the patterns and determinants of HIV risk behaviors among black and white adolescents who entered substance abuse treatment facilities across the nation. The primary goal of our analyses was to examine potential reasons why young blacks are at greater risk for HIV and other STIs compared to whites in the United States. Using a large clinical population and controlling for a variety of demographic, socioenvironmental and psychosocial risk factors, our analyses confirmed the existence of significant disparities both in the patterns of HIV risk behaviors and the factors associated with risk behaviors between blacks and whites.

Disparities in Prevalence of Sexual Risk Behaviors A little more than 76% of the adolescents in our data set report being sexually active within the 12 months prior to their admission. This is a significantly higher percentage than the <60% prevalence of sexual activity among nonclinical populations of adolescents aged <20,13,26 but it is not unusual to find similarly high or higher rates of sexual activity among substance abusing clinical populations.17 The most common forms of risk behaviors included having sex with ≥2 partners, having sex without a condom or other barriers, and having sex while they themselves or their partners are high with AODs. These are consistent with recent findings. In a study of sexually active adolescents in substance abuse treatment, 72% reported to have had sex with multiple partners in the preceding year and only 20% used a condom.27 In another study of amphetamine and heroin using black and white youth, the single most common sexual risk taking behavior was having sex while high on AODs.28 We found racial differences in sexual risk behaviors both before and after we accounted for substance abuse, symptoms of mental disorders, criminal behaviors, socioenvironmental risk factors and demographic characteristics. In our unadjusted comparisons, black adolescents appear to be less likely to engage in highrisk sexual behaviors compared to white adolescents. These findings appear somewhat contradictory to both behavioral surveillance reports as well as epidemiological data showing disproportionate prevalence of HIV risk behaviors or HIV infections, or other STIs within this group.4,5 However, in this study, the lower sexual risk profile of black adolescents occurred in the context of lower levels of substance use, symptoms of mental disorders and a number of other risk factors. Our analysis, adjusting for these factors, revealed patterns of HIV risk behaviors consistent with behavioral surveillance and epidemiological reports. The results showed that at equivalent levels of these risk factors, blacks are ≥2 times more likely than whites to have traded sex for or purchased sex with AOD, money or gifts; to have had VOL. 100, NO. 12, DECEMBER 2008 1413

HIV Risk Behaviors among Adolescents

sex with ≥2 partners; and to have used AOD to enhance their sexual experience. While the higher rates of sex with multiple partners among blacks is consistent with the literature,29 the finding that their level of protected sex is not significantly different than white adolescents is perhaps unique to this population, as black youth consistently report higher condom use rates than whites or other racial/ethnic groups.29 Overall, the higher rates of sexual risk behaviors, coupled with the absence of a concomitant higher rate of protected sex, contributed to higher overall HIV risk among black than white adolescents in this study. These findings underscore important considerations in behavioral intervention research on high-risk sexual behaviors among blacks in substance abuse treatment. From a theoretical perspective, these findings confirm that sexual risk behaviors occur in and are affected by complex social, psychological and environmental contexts. From a public health perspective, understanding and mitigating HIV risk among these adolescents require careful consideration of these contextual and broader ecological factors and the design and implementation of multisystemic and comprehensive interventions.30,31 A reductionist approach to HIV prevention focusing only on reduction of sexual behavior and without due regard to the complex environment in which these adolescent risk behaviors occur is less likely to be efficacious than one that accounts for these factors. These findings also underscore the need to provide HIV risk reduction intervention along with substance abuse treatment or prevention services.30 It is important to note that adolescents in substance abuse treatment programs may represent the best captive audience for introducing or expanding HIV prevention interventions; brief HIV interventions may be appropriate in outpatient programs, while HIV interventions integrated with substance abuse treatment may be appropriate in residential programs.

Disparities in Determinants of Sexual Risk Behaviors Given that significant differences in sexual risk behaviors are present between blacks and whites, another set of analyses was required to understand what accounts for these differences. Race-specific analyses revealed both similarities and differences in the determinants of sexual risk behaviors among blacks and whites. Among both blacks and whites, higher levels of substance use problems, longer and more frequent substance use, internalizing mental distress and drug-related crime associated with engaging in ≥2 sexual risk behaviors. Prior work suggests that these factors are commonly related to HIV risk behaviors.19 The similarities in determinants of sexual risk behaviors among blacks and whites suggest that there may exist a constellation of factors that co-occurs with sexual risk behaviors among young people in general regardless of racial background. 1414 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

Understanding and responding to the wide black– white difference in the prevalence of HIV and other STIs require, at least in part, critically examining factors that differentially contribute to engaging in HIV risk behaviors. When we examined factors associated with having sex with multiple partners or having unprotected sex, we found interesting racial disparities. Multipartnered sex was associated with being male, being from a single-parent custody household and involvement with the criminal justice system among blacks but not among whites. Each of these factors has been blamed for the spread of the HIV/AIDS epidemic among blacks in the United States29 and deserves further discussion. The association between having sex with multiple partners and being under single-parent custody is not a new finding, as both cross-sectional32,33 and longitudinal studies12,34 have also found higher rates of sexual risk, substance abuse or delinquent behaviors in youth from single-parent than 2-parent households. These studies attribute the link between single-parent family structure and adolescent sexual risk behaviors to limited parental monitoring and supervision, socioeconomic deprivation or the absence of appropriate role models (e,g., the absence of fathers for boys). What makes the findings in this study very critical is the much higher rate of black (63%) adolescents coming from single-parent households compared to white adolescents (43%) and the potential magnitude of effect this disparity may have on adolescents’ overall HIV risk. The higher rate of sex with multiple partners among black males compared to black females is consistent with the sexual behavior literature13 and gender-role expectations and norms that are prevalent in the United States and other societies.35 Adolescent and young-adult males are generally expected to take greater sexual risk, including earlier initiation of sex, having multiple partners, having sex without protection and sexual aggression against female partners.35-37 Some argue that the “hypermasculinity” of black males is a major factor in the heterosexual spread of HIV/AIDS and unintended pregnancies among black females.38 It is, therefore, imperative to design culturally sensitive and genderspecific interventions that address the unique vulnerabilities and/or social role expectations of black male and female adolescents. It has been suggested that one of the most pervasive structural factors that may partially explain black–white differences in HIV/AIDS in the United States is the disproportionately high rate of criminal justice involvement among black youth and adults compared to their white counterparts.29 In addition to the possibility that correctional facilities may constitute potentially risky environments (e.g., due to sexual assaults and unprotected sex), involvement in the criminal justice system (including arrests, incarcerations, probation and parole) may increase HIV risk in several ways, primarily through VOL. 100, NO. 12, DECEMBER 2008

HIV Risk Behaviors among Adolescents

its disruption of social networks, reduction of access to social and health services, and aggravation of economic vulnerability.29,39 Our finding of a proportionally higher rate of history of criminal justice involvement among black adolescents and its stronger association with their having multiple sexual partners is in line with the literature. Although these relationships are based on crosssectional data, it can be safely argued that the higher rates of sex with multiple partners among these adolescents may, in part, be due to the potential disruption of romantic relationships and reduced opportunities for HIV preventive education associated with criminal justice involvement. Within the context of the criminal justice system, therefore, structural interventions that aim to reduce the likelihood of black youth from getting involved with the system, to reduce HIV risk behaviors among those already involved with the system and to ease the burden of re-entry for those leaving the system may help reduce disparities in risk behaviors and HIV/ AIDS.29 Within the context of substance abuse treatment, understanding the additional HIV risk burden of those with current or past involvement with the criminal justice system may help design more responsive intervention programs. Even though there were no racial differences in the rates of unprotected sex, significant racial variations were found in factors that influence this HIV risk behavior. Among blacks, unprotected sex was significantly more likely among those with higher frequency of illicit drug use, those who used alcohol and those with drug-related offenses than those without these problems. Among whites, unprotected sex was more likely among older adolescents, those with the history of homelessness/running away and victimization, those who used opiates and those with higher levels of symptoms of mental disorders. It is interesting to note here that the determinants of unprotected sex among blacks are primarily related to drug use, whereas the determinants of unprotected sex among whites appear to be related to other social environmental risk and mental health. Despite the lower cooccurrence of substance abuse and sexual risk among nonclinical black adolescents, it has been suggested that the potential consequences of substance use on HIV risk behaviors might be stronger among blacks than among whites.18 Our findings suggest that a similar stronger effect of substance use on sexual risk may also apply in clinical populations. Before we conclude, it is important that we address some of the major limitations of this study. First, to the extent that the data for this study were derived from enrollees of federally funded substance abuse treatment programs, the results discussed above can only be generalized to black and white youth in similar programs. Second, this is also a cross-sectional study based on retrospective self-reported data on sexual behaviors collected at entry into a substance abuse treatment program. Thus, JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

as in any cross-sectional study, no conclusion regarding causal relationships can be made. Finally, our measurement of HIV risk behaviors was based on a 1-year recall period; a shorter period of recall might have produced a more reliable estimate of risk behavior, particularly among adolescents with substance abuse problems. Notwithstanding the above limitations, this study revealed that lower levels of substance use and mental health problems among blacks might minimize the black–white difference in levels of sexual risk behaviors. When these differences are taken into account, black adolescents remained at far greater risk for HIV infection and other sexually transmitted infections compared to their white peers. High-risk sexual behaviors among blacks and whites were associated with largely similar sets of risk factors, suggesting that a constellation of risk contexts may be driving this major public health problem. Although the small differences in determinants of HIV risk behaviors did not completely account for the racial disparities in risk behaviors, they provided clues regarding the potential sources of disparities in the HIV/ AIDS epidemic between blacks and whites. Further research into the sources of differences in these determinants may provide valuable information to design tailored and multisystemic interventions to reduce disparities in risk behaviors among adolescents with substance abuse problems. Such targeted and comprehensive interventions may ultimately reduce the disparity in the prevalence of HIV among black and white youth.

Acknowledgements

We are also thankful to Drs. Wilhemena Lee-Ougo and Suzanne Randolph, and 3 anonymous reviewers for their critical feedback on our manuscript.

References

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35. UNAIDS. Gender and HIV/AIDS: Taking stock of research and programmes. Geneva, Switzerland: UNAIDS; 1999. 36. O’Sullivan LF, Hoffman S, Harrison A, et al. Men, multiple sexual partners, and young adults’ sexual relationships: understanding the role of gender in the study of risk. J Urban Health. 2006;83:695-708. 37. Santana MC, Raj A, Decker MR, et al. Masculine gender roles associated with increased sexual risk and intimate partner violence perpetration among young adult men. J Urban Health. 2006;83:575-585. 38. Wolfe WA. Overlooked role of African-American males’ hypermasculinity in the epidemic of unintended pregnancies and HIV/AIDS cases with young African-American women. J Natl Med Assoc. 2003;95:846-852. 39. Khan MR, Wohl DA, Weir SS, et al. Incarceration and risky sexual partnerships in a southern U.S. city. J Urban Health. 2008;85:100-113. n

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