Increased Sexual Risk Behavior and High HIV Seroincidence among Drug-Using Low-Income Women with Primary Heterosexual Pa

1. 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. Pouget1 Rahul Hamid1 Leilani Torres1 1 National Development & Research Institutes, New York, NY 2 Tulane UniversitySchool of Public Health & Tropical Medicine, New Orleans, LA Funding provided by NIH/NIDA grants R01DA10864, R01DA12805 and R01DA15641

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. Study Setting: East Harlem, NYC Population size: Total 117, 000 Racial/Ethnic Composition: Hispanic 52%BlackNon-Hispanic 36% White Non-Hispanic 7% Social/Health Statistics: Completed high school 56% Unemployed 17% Receive public assistance 37% Income below poverty line 40% HIV seroprevalence 4.8% Infant mortality rate 9.7 per 1000 births Hospitalizations due to drug use 724 per 100,000

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

5. East Harlem HIV Risk Studies Involving Drug-Using Women and Heterosexual Couples 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. HIV and Hepatitis B and C Seroprevalence Pathogen Study I Study II Study II Women Women Men HIV 23.3% 22.1% 22.0% (119/510) (74/335) (75/341) HBV 52.4% 43.1% 47.8% (220/420) (128/297) (144/301) HCV 43.1% 51.5% 52.7% (182/422) (153/297) (159/301)

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 71% 46% Primary 41% Casual 11% 16% 6% 8% 13% Exchange 5% 32%

10. Percent Consistent Condom Use by Partner TypeStudies 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- CouplesBy Women’s Awareness of Partner’s HIV Status (CAR, n=39) 69% 31% (last 30 days)

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

15. Women’s Relative Risk of Acquiring HIV from Different Types of Sex Partners Risk from PMPs:More common Lower condom useMore freq. exposureSingle Partner Risk from Non-PMPs:Less common Higher condom useLess freq. exposureMultiple partners

16. P 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 Primary male partner C S X Subject: uninfected female drug-user Casual sex partner Exchange sex partner F 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).

17. Model-Predicted HIV Incidence (DUSC, n=390)Seroconversions per 100 person-years

18. 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.