1. 1 National Development & Research Institutes, New York, NY 2 Tulane University School of Public Health & Tropical Medicine, New Orleans, LA Funding provided by NIH/NIDA grants R01DA10864, R01DA12805 and R01DA15641 Increased Sexual Risk Behavior and High HIV Seroincidence among Drug-Using Low-Income Women with Primary Heterosexual Partners James M. McMahon, Ph.D. 1 Stephanie Tortu, Ph.D. 2 Enrique R. Pouget 1 Rahul Hamid 1 Leilani Torres 1

2. Study Background & Objectives: Heterosexual transmission of HIV continues to rise among women in many parts of the world. Previous research has shown that characteristics of sexual partnerships have an important influence on HIV risk among women. This study examined HIV risk among women drug- users in East Harlem, NYC, to assess women’s relative risk from different types of sexual partners. The findings from this study will help inform the development of HIV prevention programs tailored to women’s specific risk partnerships.

3. Population size: Total 117, 000 Racial/Ethnic Composition: Hispanic52% Black Non-Hispanic 36% White Non-Hispanic 7% Social/Health Statistics: Completed high school56% Unemployed17% Receive public assistance37% Income below poverty line40% HIV seroprevalence 4.8% Infant mortality rate 9.7 per 1000 births Hospitalizations due to drug use 724 per 100,000 Study Setting: East Harlem, NYC

4. East Harlem (“El Barrio”), New York City:

5. East Harlem HIV Risk Studies Involving Drug-Using Women and Heterosexual Couples Study Study I (DUSC) Women Drug Users in Social Context Study II (CAR) Couples at Risk S. Tortu, PI A. Neaigus, Co-I S. Tortu, PI J.M. McMahon, Co-I Time frame 1996 - 19992000 - 2003 Sample 601 drug-using women353 drug-using women and their primary partners Eligibility >18; female; current use of crack, cocaine or heroin (IDU or non-IDU); sexually active >18; female and male primary partners; current use of crack, cocaine or heroin (IDU or non- IDU); sexually active Recruitment Street-recruited, client- referral Female targeted, street- recruited, client-referral Data collection Survey on demographics, health, sex & drug risk, risk context & partnerships; all offered HIV, HBV, HCV counseling and testing

6. DUSC & CAR Sample Descriptors

7. PathogenStudy I Study II Study II WomenWomenMen HIV23.3%22.1%22.0% (119/510) (74/335) (75/341) HBV52.4%43.1%47.8% (220/420) (128/297) (144/301) HCV43.1%51.5%52.7% (182/422) (153/297) (159/301) HIV and Hepatitis B and C Seroprevalence

8. Operational Definitions of Sexual Partnerships: Primary Male Partner (PMP): Legal or common-law husband or steady primary boyfriend of at least one year. Sex Exchange Partner: A sexual partner with whom sex was exchanged directly for money or drugs. Casual Sex Partner: A sexual partner who is neither a primary nor exchange partner (e.g., one-time sex partner or regular casual sex partner).

9. Concurrent Sexual Partnerships (DUSC n=601): Prior 6 months self-reported Primary 41% Casual 11% Exchange 5% 71% 46% 32% 13% 8% 6% 16%

10. Location/SourcePrimaryCasualExchangeTime Frame East Harlem (Tortu-DUSC)254375 Last intercourse East Harlem (Tortu-CAR)22-- Philadelphia (Watkins)275280 Washington, DC (Williams)205261 N. California (Ruiz)3051- East Harlem (Tortu-DUSC)23-- Last 30 days East Harlem (Tortu-CAR)194365 Birmingham (Cabral)24-- U.S. Multisite (Harvey)24-- Last 3 months Seattle (Baker)1426- Percent Consistent Condom Use by Partner Type Studies on U.S. Urban Populations

11. Cumulative Unprotected Vaginal Sex (DUSC n=601): By Partner Type (12 months)

12. Cumulative Unprotected Anal Sex (DUSC n=601): By Partner Type (12 months)

13. Unprotected Sex by Male+/Female- Couples By Women’s Awareness of Partner’s HIV Status (CAR, n=39) 69% 31% (last 30 days)

14. Solitary: Woman injected alone Social: Women injected with other IDUs Women’s Injection Practices Last Injection Event (DUSC, n=185)

15. Women’s Relative Risk of Acquiring HIV from Different Types of Sex Partners Risk from PMPs: More common Lower condom use More freq. exposure Single Partner Risk from Non-PMPs: Less common Higher condom use Less freq. exposure Multiple partners

16. F CX P S Subject: uninfected female drug- user Primary male partner Casual sex partnerExchange sex partner Friends, family, running buddy Mathematical Modeling: HIV Seroincidence Estimated from Self-Reported Risk Behavior and HIV Transmission Parameters 1. Individual Probability (P) of HIV Seroconversion: Bernoulli equations applied to each individual in the sample to calculate probability of HIV seroconversion based on self-reported risk behavior. 2. HIV Seroincidence: Sample mean P used to calculate model-based estimate for seroincidence over the entire sample (number of seroconversions per 100 person years). Male-to-Female Transmission Probability per Act: Vaginal intercourse (.001) Anal intercourse (.02) Syringe sharing (.01) Condom Use: Rate of effectiveness (.90) Probability of Risk Partner Being Infected: 0 to 1.0 depending on partner type and characteristics Number of Partners By partner type

17. Rate:# of infections: Total sample of 390 HIV- women2.77 11 From primary partner2.13 8 From casual partner0.18 1 From exchange partner0.46 2 Model-Predicted HIV Incidence (DUSC, n=390) Seroconversions per 100 person-years

18. Rate:Rel Risk: Model-Predicted HIV Incidence From primary partner (subset n=575 with PMPs) 2.54Ref. From casual partner (subset n=79 with casual partners) 1.06-2.40 From exchange partner (subset n=122 exchangers) 1.36-1.87 Actual Observed HIV Incidence Cohort of repeat testers from DUSC & CAR: 4 seroconversions of 52 women with PMPs over 3.22 yrs 2.48 (95% CI:.07, 6.35) Estimated HIV Seroincidence (DUSC & CAR, n=651) Seroconversions per 100 person-years

19. Conclusions: Drug-involved women from East Harlem, New York City… …exhibit one of the highest rates of HIV infection in the United States …are at greatest risk of acquiring HIV from primary male partners …continue to engage in sex- and drug-related HIV risk behavior with infected or high-risk male partners Preliminary data suggest a high rate of HIV seroconversions among women drug-users with PMPs Interventions promoting “monogamy” may not help these women avoid disease due to the high risk of acquiring HIV from primary male partners

20. Acknowledgements: This work was supported by research grants from the U.S. National Institutes of Health/National Institute on Drug Abuse (R01DA10864, R01DA12805 and R01DA15641). The authors thank the dedicated staff (former and present) of the DUSC, CAR & CHIP projects: Sherelle Bonaparte, Jeanine Botta, Hanifah Burns, Jeanne Campbell, Audrey Grandy-Lampkin, Robert Quiles, William Rodriguez, and Lee Wengraf. We also thank the men and women who participated in the DUSC and CAR studies.