1. Crack Cocaine, HIV, and African American Women Alison Hamilton, Ph.D. alisonh@ucla.edu UCLA Department of Psychiatry Integrated Substance Abuse Programs November 5, 2008

2. HIV Incidence In 2005, 49% of those diagnosed with HIV/AIDS were African American (including children), though African Americans make up only 13% of the US population In 2004, women accounted for 27% of new HIV infections Among women living with HIV/AIDS in 2005, 64% were African American Source of infection for women: 78% of new infections due to heterosexual contact

3. African Americans & HIV For African American women, the most common ways of getting HIV are having unprotected sex with a man who is infected, and sharing injection drug works with someone who is infected Those at higher risk are: unaware of their partner’s status, infected with other STDs, and/or living in poverty Useful fact sheet: http://www.cdc.gov/hiv/topics/aa/resources /factsheets/pdf/aa.pdf http://www.cdc.gov/hiv/topics/aa/resources /factsheets/pdf/aa.pdf

4. African American Women & HIV In a 2004 study, women who used crack cocaine were less likely (than women who did not) to take antiretroviral medicines as prescribed High rate of other STDs among African Americans: can increase chances of HIV infection by 3-5x Women living in SPA 6 (South) have 2-3x higher chlamydia, gonorrhea and primary and secondary syphilis rates compared to the overall rates for women in Los Angeles County. Los Angeles County public health report: http://publichealth.lacounty.gov/wwwfiles/ph/hae/ha /WomensHealthIndicators05.pdf http://publichealth.lacounty.gov/wwwfiles/ph/hae/ha /WomensHealthIndicators05.pdf

5. Women’s Circumstances Demographic (age, education, etc.) and structural barriers (homelessness, poverty, etc.) affect a woman’s ability to change life circumstances Childhood histories of abuse and drug use common among crack cocaine users  disempowered adult relationships Historical issues & contextual factors may especially jeopardize poor African American women who are already at greater risk for HIV infection

6. Intimate Partner Violence (IPV) & HIV Recent attention being paid to IPV Annually, 1.5 million women raped or physically assaulted by intimate partner Lifetime rates of IPV between 21-55% “Gender-based violence” among pregnant women and HIV+ women ranges from 8%-38% SEVERAL WAYS IN WHICH HIV & IPV INTERSECT –Often those with high rates of IPV are same groups also at high risk for HIV (young women, drug users, women living in poverty)

7. Intimate Partner Violence Abuse & Fear (coercion & control) increase RISK for HIV transmission HIV-positive women may experience IPV as RESPONSE to disclosure of infection

8. Comparing HIV- and HIV+ women Higher severity of IPV among HIV+ women HIV+ women experience more frequent abuse and report more severe trauma histories Cumulative violence: 2 or more types of violence = 5x more likely to have recent STI

9. Women Who Use Crack Crack-using women are an important group affecting the HIV epidemic in their communities because of the high risks of becoming infected as well as transmitting to others Subpopulations engage in high-risk sexual activities (e.g., exchange of sex for money and drugs) Crack cocaine use is associated with both delayed entry into HIV primary care and reduced medication adherence HIV+ crack-using women are likely to have high viral loads and are at high risk of transmitting HIV to sexual partners Use of crack cocaine associated with high rates of sexually transmitted infections and vaginitis, which increase the potential for HIV transmission

10. What Research Has Found Women crack users with multiple partners differed from women with single partners as they are more likely to: Be homeless Be financially dependent Have experienced a difficult childhood Have much heavier drug use (higher rates of daily alcohol use and crack use, longer crack runs, higher doses of crack) Have symptoms of depression, anxiety, and PTSD But women with single partners had more unprotected sex, so they are also at risk; 62% believed they were at risk for HIV (88% of women with multiple partners believed they were at risk)

11. What Research Has Found HIV-positive persons who use crack cocaine engage in sexual risk behaviors at relatively high rates and may be at an especially high risk for HIV transmission or re-infection. In a study of 10,415 HIV-positive heterosexual men, heterosexual women, and men who have sex with men, Campsmith et al. found that those who continued to use crack after HIV diagnosis (n = 2,361) reported the highest prevalence of unprotected sex, multiple partners, and exchanging sex for drugs or money regardless of sexual orientation and gender.

12. What Research Has Found Among 303 African-American, HIV-positive users: 51% reported a recent crack binge (typical crack binge = 3.7 days and smoking 40 rocks) Nearly two-thirds reported their last binge was in their own or another’s home 72% had sex during the last binge, with an average of 3.1 partners Recent bingers were more likely than non-bingers to consider themselves homeless, to not have any income source, to have used crack longer, and to score higher on risk-taking and need for help with their drug problem Recent bingers had more sex partners in the last six months and in the last 30 days and were more likely to have never used a condom in the last 30 days. Among both male and female users, recent bingers were more likely to report lifetime trading of sex for drugs.

13. What Role Can Drug Treatment Play? Large study conducted over 8 years with 1,658 drug-using women (57.5% African, 80.3% HIV positive; 49.6% crack/cocaine users): Drug treatment was not associated with subsequent consistent condom use, regardless of frequency of attendance, but involvement in at least three treatment programs was related Additional efforts are needed to integrate effective sexual risk reduction programs into drug treatment settings; expanding access to different types of drug treatment modalities may be indicated.

14. Best-Evidence Interventions Wechsberg & colleagues: Sample = Out-of-drug-treatment African American women (n = 620) who use crack Only woman-focused intervention participants consistently improved employment and housing status Woman-focused intervention participants were least likely to engage in unprotected sex Sterk & colleagues: Sample = 71 African American women who injected crack Substantial decreases in the frequency of drug use and the frequency of drug injections; sharing of injection works or water; number of injections. Trading sex for drugs or money, having sex while high, as well as other sexual risk behaviors were also reduced significantly Women in both enhanced intervention conditions were more likely to reduce their drug using and sexual risk behaviors than women in the standard condition.

15. Interventions for HIV & IPV risk No studies specifically designed to reduce both risk of HIV and IPV  no best practice evidence Consider “sexual risk reduction hierarchy” - provide women with a range of options offering varying levels of protection Need multisystem involvement and collaboration with perpetrators’ programs

16. Summary Disproportionate prevalence and incidence of HIV/AIDS in African Americans African American women significantly affected by HIV & other STDs African American women who use crack at significant risk for HIV infection, and HIV+ women at significant risk for not getting needed services and maintaining medication regimens Risk is complicated by structural barriers and interpersonal barriers such as intimate partner violence Some interventions are promising for reduction of sexual risk, but few address structural barriers and the combined set of risk factors that many women face on a daily basis