Wendee M. Wechsberg

Substance Use, Sexual Risk, and Violence: HIV Prevention Intervention with Sex Workers in Pretoria

This paper describes an HIV prevention intervention designed in the US that was adapted and implemented in South Africa. Using an experimental design, 93 women who reported recent substance use and sex trading were randomly assigned to a modified Standard HIV intervention or to a Woman-Focused HIV prevention intervention. Eighty women completed the one-month follow-up interview. Participants reported high rates of sexual risk and violence at baseline. At follow-up, findings showed decreases in the proportion of women reporting unprotected sex and the daily use of alcohol and cocaine. Daily alcohol and cocaine use decreased more for women receiving the Woman-Focused intervention. Although violence continued to be a problem, at follow-up Woman-Focused participants reported being victimized less often than women receiving the Standard intervention. This study demonstrates the feasibility of implementing cross-cultural behavioral HIV prevention interventions, and supports the need for future studies of womens contextual issues and the effectiveness of targeted interventions.

Efficacy of a Woman-Focused Intervention to Reduce HIV Risk and Increase Self-Sufficiency Among African American Crack Abusers

OBJECTIVES This study compares 3- and 6-month outcomes of a woman-focused HIV intervention for crack abusers, a revised National Institute on Drug Abuse standard intervention, and a control group. METHODS Out-of-drug-treatment African American women (n = 620) who use crack participated in a randomized field experiment. Risk behavior, employment, and housing status were assessed with linear and logistic regression. RESULTS All groups significantly reduced crack use and high-risk sex at each follow-up, but only woman-focused intervention participants consistently improved employment and housing status. Compared with control subjects at 6 months, woman-focused intervention participants were least likely to engage in unprotected sex; revised standard intervention women reported greatest reductions in crack use. CONCLUSIONS A woman-focused intervention can successfully reduce risk and facilitate employment and housing and may effectively reduce the frequency of unprotected sex in the longer term.

Violence against substance-abusing South African sex workers: intersection with culture and HIV risk

Abstract The Republic of South Africa has become an epicentre of heterosexual HIV transmission among Black women, and the interface between violence against women, substance abuse, and HIV risk is becoming evident. This paper describes the characteristics of Black South African women who engage in sex work in Pretoria and examines their intersecting experiences of high-risk sexual behaviour, substance abuse, and victimization. Ninety-three women were recruited into the study. Field staff collected biological measures of drug use and administered a structured, self-report interview. Findings indicate that young South African women who engage in sex work and use drugs rely on this activity as their main source of income and are supporting other family members. The majority of sample women reported experiencing some victimization at the hand of men, either clients or boyfriends, with many reporting childhood abuse histories; young women also report great fear of future victimization. Findings also suggest that as a result of their decreased likelihood of using protection, women who reported any sexual or physical victimization are at increased risk for HIV and other STIs. Results support the critical need for targeted, comprehensive interventions that address substance abuse, sexual risk, and violence as interrelated phenomena.

Violence, Homelessness, and HIV Risk among Crack-Using African American Women:

This study compares the characteristics of out-of-treatment, homeless, crack-using African-American women with those who are not homeless to determine what risks and protective factors differentiate the two groups. From 1999 to 2001, 683 out-of-treatment, African-American crack-using women (of whom 219 were categorized as homeless) were interviewed and serologically tested. Risk factors that were examined include adverse childhood experiences, psychological distress, physical health, violence and victimization, drug use, and risky sex behaviors. Protective factors that were examined include marital status, education, public assistance, and the responsibility of caring for children. Overall, both groups of women started crack use in their mid-twenties and started drug use with alcohol in their teenage years, though differed significantly on each risk factor examined. Logistic regression analysis found that variables associated with increased odds of being homeless are physical abuse before age 18, crack runs greater than 24 hours, income less than

Alcohol, cannabis, and methamphetamine use and other risk behaviours among Black and Coloured South African women: A small randomized trial in the Western Cape

500 in the last 30 days, depression, and current cigarette smoking. Protective factors found are marital status, living with children under 18, having had a physical in the past year, and receiving money from welfare in the last 30 days. Being sexually assaulted in the past 90 days was marginally associated with homelessness in the model. These findings, specific to crack-using African-American women, suggest that not only do these women overall report painful histories and currently stressful lives, but homeless women are more likely than women who are not homeless to have experienced childhood abuse and are more involved with drug use. Interventions designed for these women need to consider gender, cultural, and contextual issues that not only incorporate aspects of risk reduction related to violence, alcohol use, and comorbid conditions, but also linkages that will address housing issues, education, and skills for independence.

Substance Use and Sexual Risk Within the Context of Gender Inequality in South Africa

BACKGROUND There is a pressing need for brief behavioural interventions to address the intersection of high HIV prevalence, increasing substance use, and high-risk sex practices among South African women. The primary aim of this pilot, randomized trial was to examine whether an adapted evidence-based intervention would be equally, more, or less effective at reducing HIV risk behaviours when delivered using an individual or group format. The secondary aim was to examine differences between Black and Coloured South African women across pre- and post-intervention measures of alcohol and illicit drug use and sex risk behaviours. METHODS The Cape Town Womens Health CoOp was adapted from an evidence-based intervention known as the Womens CoOp. Study participants included Black (n=60) and Coloured (n=52) women living in the township communities of Cape Town, South Africa, who reported using illicit drugs and alcohol. RESULTS Coloured women reported greater methamphetamine use (13 days in the past 30 days) and Black women reported mostly cannabis use (27 days in the past 30 days). Although both groups reported having unprotected sex under the influence of alcohol and/or other drugs, Black women reported greater condom use and having one partner; Coloured women reported having more than one sex partner. One-month post-intervention assessments indicated significant reductions in substance use and sex risk behaviours. After controlling for baseline measures, there were no significant differences between the two intervention conditions. CONCLUSION Significant differences in risk behaviours were observed between Black and Coloured South African women. However, both ethnic groups were responsive to the adapted intervention and no differences were found by intervention assignment. These findings support the assertion that group interventions may be more cost-effective in reaching at-risk women in resource-scarce environments. Larger studies are needed to show efficacy and effectiveness of woman-focused group prevention interventions.

Double jeopardy--Drug and sex risks among Russian women who inject drugs: Initial feasibility and efficacy results of a small randomized controlled trial:

This study examines substance use and sexual risk within the context of gender inequality among 163 women from an urban region of South Africa who were participating in a 2004–2006 study funded by the National Institute of Alcohol Abuse and Alcoholism. Items assessed patterns of substance use, gender inequality, risk communication, and psychological distress. Multivariate logistic regression analyses revealed that economic dependence on a main partner and traditional beliefs about a womans right to refuse sex were associated with substance use prior to or during sex with that partner. The findings demonstrate that substance abuse prior to sex may reinforce traditional beliefs and that women with more progressive beliefs about gender ideology seem better able to control their substance use in risky environments.

Behaviorally Bisexual Men and their Risk Behaviors with Men and Women

BackgroundWith HIV prevalence estimated at 20% among female injecting drug users (IDUs) in St. Petersburg, Russia, there is a critical need to address the HIV risks of this at-risk population. This study characterized HIV risks associated with injecting drug use and sex behaviors and assessed the initial feasibility and efficacy of an adapted Woman-Focused intervention, the Womens CoOp, relative to a Nutrition control to reduce HIV risk behaviors among female IDUs in an inpatient detoxification drug treatment setting.MethodWomen (N = 100) were randomized into one of two one-hour long intervention conditions--the Woman-Focused intervention (n = 51) or a time and attention-matched Nutrition control condition (n = 49).ResultsThe results showed that 57% of the participants had been told that they were HIV-positive. At 3-month follow-up, both groups showed reduced levels of injecting frequency. However, participants in the Woman-Focused intervention reported, on average, a lower frequency of partner impairment at last sex act and a lower average number of unprotected vaginal sex acts with their main sex partner than the Nutrition condition.ConclusionThe findings suggest that improvements in sexual risk reduction are possible for these at-risk women and that more comprehensive treatment is needed to address HIV and drug risks in this vulnerable population.

Methamphetamine use and risky sexual behaviors during heterosexual encounters.

Gay and bisexual men are often treated as a homogenous group; however, there may be important differences between them. In addition, behaviorally bisexual men are a potential source of HIV infection for heterosexual women. In this study, we compared 97 men who have sex with men only (MSM) to 175 men who have sex with men and women (MSMW). We also compared the 175 MSMW to 772 men who have sex with women only (MSW). Bivariate and multiple logistic regression analyses were performed to assess correlates of MSMW risk behaviors with men and with women as well as whether MSMW, compared with MSW, engaged in more risky behaviors with women. Compared with MSM, MSMW were less likely to be HIV-positive or to engage in unprotected receptive anal intercourse. In contrast, MSMW were more likely than MSW to be HIV-positive and to engage in anal intercourse with their female partners; however, rates of unprotected anal intercourse were similar. The study findings suggest that there may be important differences in HIV risk behaviors and HIV prevalence between MSM and MSMW as well as between MSMW and MSW.

The effect of treatment completion and length of stay on employment and crime in outpatient drug-free treatment

Objective: This study examined the association between event-level methamphetamine use and heterosexual risk behaviors. Method: Data on 1213 heterosexual encounters were collected using audio-computer assisted self interviews from 703 injecting drug users in North Carolina. Data were obtained by asking participants a series of questions about the last time that they had sex (oral, vaginal, and/or anal). Although participants were interviewed at up to 3 time points, data were analyzed at the event level rather than as longitudinal because we were interested in the co-occurrence of methamphetamine use and sexual risk behaviors. Multivariate generalized estimating equations models were developed to examine the association between co-occurring methamphetamine use and each of 6 heterosexual risk behaviors. Results: Methamphetamine was used in 7% of encounters. Methamphetamine use by either or both partners was associated with an increased likelihood of anal intercourse (odds ratio [OR] = 2.41, 95% confidence interval [CI] = 1.29–4.53), vaginal and anal intercourse (OR = 2.41, 95% CI = 1.22–4.77), and sex with a new partner (OR = 1.98, 95% CI = 1.09–3.61). In addition to these behaviors, methamphetamine use by both partners was also significantly associated with unprotected intercourse with a new partner (OR = 5.20, 95% CI = 2.09–12.93) and unprotected anal intercourse (OR = 4.63, 95% CI = 1.69–12.70). Conclusions: Methamphetamine use during heterosexual encounters appears to increase sexual risk-taking, especially when both partners are using it.