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

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.

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 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 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.