Male and female rural probationers: HIV risk behaviors and knowledge.

Individuals involved in the criminal justice system are at substantial risk for HIV infection and have elevated rates of AIDS. Offenders under community supervision, such as probationers, have substantially more opportunities to engage in high-risk behaviors than prisoners. Furthermore, probationers in rural areas are at risk because rural areas may be slower to adopt HIV risk-reduction approaches. Consequently, the primary goal of this study is to describe the HIV risk behaviors and level of HIV knowledge of 800 rural felony probationers. Bivariate results indicate that males have substantially greater criminal histories and engage in more substance use risk behaviors than females. Overall, there was minimal and inconsistent use of condoms, but there were no significant differences by gender. Gender differences prevailed in perceived HIV knowledge, with females reporting high levels of perceived HIV knowledge. Multivariate models did not support the hypothesis that perceived knowledge would be a more robust correlate of scores on the HIV Risk Behavior Knowledge Test for males than females. Results suggest that rural residents are not protected from engaging in HIV risk behaviors and future studies should examine gender discrepancies between perceived and actual HIV knowledge among offenders under community supervision.

Tailoring an HIV-prevention intervention for cocaine injectors and crack users in Porto Alegre, Brazil.

Brazil has the second largest number of reported AIDS cases in the world. Porto Alegre, like most other large urban centres in Brazil, has been greatly impacted by an AIDS epidemic driven by high rates of drug use and risky sexual behaviours. While epidemiologic surveillance of HIV/AIDS and treatment initiatives for HIV-infected individuals are well developed in Brazil, comparatively little attention has focused on developing interventions directed toward high-risk populations. Intervention programmes, particularly those tailored for chronic drug users, are lacking. This pilot project successfully adapted and tailored a cognitive behavioural HIV intervention developed in the US to the cultural setting in Porto Alegre. The project established feasibility and acceptability of the approach for targeting risky drug and sexual behaviours among a group of male Brazilian drug users. A sample of 120 male cocaine users was recruited from a public health clinic serving the target population in the city of Porto Alegre. The average age of the participants was 29; they averaged less than 8 years of formal education; and less than half (41%) were married. Lifetime self-reported drug use was high with 93% reporting cocaine use, 87% reporting crack use, and 100% reporting marijuana use. 43% of the sample reported ever injecting drugs. Reports of risky sexual behaviours were similarly elevated. Almost half (45%) tested positive for HIV. Preliminary evidence suggests that intervention acceptability was high among participants. Given the reported high risk sexual and drug use behaviours among these men, HIV interventions must be evaluated and expanded to include this population as well as their sexual partners.

Health service utilization and victimization among incarcerated female substance users.

Women represent the fastest growing population of prison inmates, which has increased dramatically in the past decade. Generally, women use more health services than men but with limited access to health care, incarcerated women tend to experience multiple problems, including problems with drugs, alcohol, and victimization. The purpose of this exploratory qualitative study was to identify specific factors related to health, mental health, drug use, and violence among incarcerated female substance users. Perspectives from 34 females who participated in focus groups in prison are discussed. Key findings indicate that drug use, victimization, and living in a rural area were barriers to accessing health services. In addition, implications for interventions targeting women are presented.

Substance use health services research.

This report provides an introduction to substance use health services research based upon the conceptual model of Andersen and Aday and demonstrates how the subsequent papers provide important insights into issues raised in this conceptual model. These issues include access and barriers to health care, needs for care, health care utilization, outcomes of care, and costs of care. We show how these issues are also expanded beyond more traditional definitions. We conclude by indicating some broad areas for further research.

History of head injury among substance users: preliminary findings.

Traumatic brain injury is associated with a variety of problems in cognitive functioning that may be related to substance use and that may influence recovery. This pilot study of 591 inmates in medium and minimum-security prisons examined self-reports of head injury, mental health problems, and health service utilization in three groups: no head injury, one head injury, and two or more head injuries. The group with multiple head injuries reported significantly more emergency room visits, more hospital admission, and number of hospital stays when compared with those with no head injury. This preliminary analysis reflects a need for additional research on brain injury among substance misusers.

Age differences in HIV risk behaviors and drug treatment utilization among drug users in Kentucky.

The purpose of this study was to (1) profile demographic and other characteristics of two age groups, younger aged 30 to 39 (N = 643), and older aged 40 to 49 (N = 395), (2) examine and identify differences in lifetime drug use patterns and age of drug use initiation, (3) examine HIV risk behaviors: drug use and sexual practices, (4) compare drug user treatment utilization between the two age groups, and (5) examine barriers to drug is treatment utilization by gender. The study sample (N = 1038) was drawn from individuals recruited into the NIDA Cooperative Agreement in Kentucky. The median age in the study sample was 38, the majority were male (72%), and African-American (81%). Results indicate that older subjects initiated drug use at a later age than younger subjects. Compared to the younger age group, significantly more subjects in the older group reported having ever used any of the 10 drugs examined. Injection drug use patterns and lifetime sex exchange practices were more prevalent in the older age group. Older subjects also were more likely to utilize drug user treatment, specifically methadone maintenance treatment. When barriers to drug user treatment were examined, significantly more women than men did not qualify for treatment, and they did not have enough money for treatment. Implications for interventions are discussed.

Rural-urban differences in substance use and treatment utilization among prisoners.

Surveys of incarcerated offenders and arrestees consistently report high rates of both alcohol and drug use in this population. This drug-crime connection has highlighted the need to learn more not only about drug treatment effectiveness, but also about drug treatment utilization. While studies have begun to examine drug treatment utilization, most of these studies have been based on urban substance abusers. Little is known about the extent to which urban and rural substance abusers may be different in terms of treatment utilization. This study, therefore, examines differences between urban and rural drug use patterns and treatment utilization among chronic drug abusers to determine whether, and in what ways, rurality may affect substance abuse and treatment seeking. The study examines these issues in a group of chronic drug users who were incarcerated at the time of the study. Findings show significant differences in drug use and treatment utilization of urban and rural offenders. Chronic drug abusers from rural and very rural areas have significantly higher rates of lifetime drug use, as well as higher rates of drug use in the 30 days prior to their current incarceration than chronic drug abusers from urban areas. Nonetheless, being from a very rural area decreased the likelihood of having ever been in treatment after controlling for the number of years using and race. While problem recognition appears to explain much of the effect of very rural residence on treatment utilization for alcohol abuse, the effects of being from a very rural area on seeking treatment for drug abuse remain statistically significant even after controlling for several other variables. The findings point to the importance of providing culturally appropriate education to very rural communities on the benefits of substance abuse treatment and of providing substance abuse treatment within the criminal justice system.

Personality disorders as extreme variants of common personality dimensions: can the Five-Factor Model adequately represent psychopathy?

The present study examined Widiger and Lynam's (1998) hypothesis that psychopathy can be represented using the Five-Factor Model (FFM) of personality. Participants in the study consisted of 481 21-22-year-old men and women who are part of an ongoing longitudinal study. Psychopathy was assessed by the degree of similarity between an individual's NEO-PI-R and an expert-generated FFM psychopathy prototype. The expert-based prototype supported the account of Widiger and Lynam (1998), as did the correlations between the NEO-PI-R Psychopathy Resemblance Index (PRI) and the individual personality dimensions. The PRI was also related in predicted ways to measures of antisocial behavior, drug use, and psychopathology. The results support the contention that psychopathy can be understood as an extreme variant of common dimensions of personality, and underscore the utility of a dimensional model of personality disorders.

The association of testosterone with nicotine use in young adult females.

This pilot laboratory study examined the relationship of testosterone levels, carbon monoxide (CO) levels, current and adolescent nicotine use, and histories of pubertal onset in 30 young adult female smokers. These females had completed questionnaires regarding nicotine use in the 7th through 10th grades, and again at age 21 as part of a cohort study of drug use. In addition, history of pubertal onset was obtained at age 21, as were testosterone and CO levels. Testosterone levels were positively correlated with cigarette use in the last 30 days (P< or =.01), CO levels (P< or =.05), cigarette use reported in the 7th and 10th grades (P< or =.05), and negatively correlated with age of pubertal onset (P< or =.001). The relationship of testosterone to nicotine will be discussed.

Assessing the differential impact of an hiv prevention intervention: who's putting the message into practice?

Recent data suggest that educational interventions aimed at reducing HIV risk behaviors have shown some success. Nonetheless, HIV risk behaviors are not always reduced by interventions and probably do not reduce risk behavior randomly. That is, the success of interventions may be related to participant characteristics. Identifying participant characteristics related to both intervention completion and reduction in risk behaviors may be useful for further developing explanatory models of health behavior and for targeting and customizing interventions. In this study differences between participants who completed an AIDS educational intervention (N = 741) and those who did not complete the intervention are first examined (N = 652) and then variables related to reducing drug and sexual risk behaviors among those who completed the intervention and follow-up interviews are examined. Results show that the majority of respondents report decreasing five out of six risk behaviors, with the smallest percentage (48.8%) decreasing rates of unprotected sex and the largest percentage (83.4%) decreasing frequency of drug injection. Different variables were found to be related to changes in the various risk behaviors. However, some relatively consistent results emerge. For all risk variables, the frequency of the specific behavior at baseline predicted the amount of change in that behavior, with those having higher levels of risk behaviors reducing their behavior the most. Positive HIV test results significantly decreased three of the four sexual risk behaviors examined, and living in a very rural area was found to be significantly related to three of the six risk behaviors. However, perceived chance of getting AIDS did not significantly reduce any of the risk behaviors. Gender and education level were also not related to changes in any of the risk behaviors. Implications include the importance of developing approaches to retain higher proportions of younger participants, males and homeless in interventions. It is particularly important to develop specific approaches to retain women in interventions. Because very rural participants were more likely to decrease crack use and alcohol or drug use with sex, rural interventions should target these behaviors at the outset of the intervention.

HIV risk behavior among bisexual and heterosexual drug users.

This study examined the sexual and drug use behaviors for bisexual and heterosexual drug users (n=11,435 males and n=5,636 females) who participated in the NIDA AIDS Cooperative Agreement study. Results of the study suggest that, for males, bisexuality was highly associated with being homeless, having ever been paid for sex, having five or more sex partners in the month preceding the interview, having an IV drug-using sexual partner in the month preceding the interview, using crack, and sharing injection equipment in the month preceding the interview. For females, bisexuality was associated with ever having been arrested, past substance abuse treatment, ever having been paid for sex, ever having paid for sex, having five or more sexual partners in the month preceding the interview, ever using cocaine, and sharing injection equipment in the month preceding the interview. Overall, results from this study indicate that both male and female bisexuals, when compared to heterosexuals, were at higher risk for HIV and were more likely to be HIV positive. One implication of these results is that a universal prevention message may not be as effective as targeting prevention messages specifically for bisexual males and females.

Stalking as a variant of intimate violence: implications from a young adult sample.

There is a limited but growing literature which suggests that stalking is a variant of intimate violence. The purpose of this study was to examine physical, psychological, and stalking victimization and perpetration among males and females. Alcohol use was also examined. The sample was 46 male and 84 female undergraduate students who reported stalking victimization and perpetration after a difficult breakup, and psychological and physical victimization and perpetration during that specific relationship. Overall, 27% of the sample study was classified into the stalking victimization group, which is consistent with other stalking prevalence rates among college samples. For females, stalking victimization was significantly associated with physical and psychological abuse victimization. For males, stalking victimization was significantly associated with psychological abuse victimization. However, there was also a strong significant reciprocal relationship of stalking and psychological abuse victimization and perpetration, especially for males. Also, alcohol use was significantly associated with victimization and perpetration of stalking and psychological abuse for males. The data from this study contribute to the hypothesis that stalking is a variant of or extension of intimate violence, especially for females. Implications and recommendations for future research are discussed.

Homelessness and gender in out-of-treatment drug users.

This study examines 5225 out-of-treatment crack users and drug injectors drawn from five different geographic areas to examine selected factors associated with homelessness. Of these crack users, 27% considered themselves undomiciled, and 60% had previously entered some type of drug treatment. Logistic regression found that substance abusers who were married, female, and persons of color were less likely to be without a home when other variables were controlled. Trading sex for money and perceived chance of getting acquired immunodeficiency syndrome (AIDS) were associated positively with homelessness, while participating in methadone detoxification and methadone maintenance programs seemed to offer some protection from homelessness.

Card Perseveration Task performance and post-task feeling states: relationship to drug use in adolescents.

This study examined whether performance on the Card Perseveration Task (Card Task) and self-report of feeling state after the task are related to self-report of drug use. The evaluation was of 64 adolescents from an adolescent psychiatric outpatient clinic (40 males, aged 15.5 years, SD = 1.6; 24 females aged 16.9 years, SD = 1.5). Drug use histories were obtained using a substance dependence symptom checklist based on DSM-III-R. The Card Task was administered, and after completion, a Post-Task Self-Report (PTSR) was administered. A factor analysis with varimax rotation grouped the 28 items of the PTSR into Distress, Happy, Satisfied, and Wanting to Win subscales. Correlations of drug use with performance on the Card Task and the PTSR subscales were obtained. Cards Played on the Card Task were correlated with alcohol (cc = .31, p < or = .01); marijuana (cc = .35, p < or = .01) and polydrug (cc = .26, p < or = .05) dependence symptoms. Money Won on the Card Task was correlated negatively with nicotine (cc = -.26, p < or = .05) and marijuana (cc = -.27, p < or = .05) dependence symptoms. The PTSR Distress subscale correlated with nicotine (cc = .49, p < or = .001), alcohol (cc = .37, p < or = .01), marijuana (cc = .39, p < or = .01), and polydrug (cc = .49, p < or = .001) dependence symptoms. These findings provide evidence that both the Card Task and feeling states associated with task performance are related to self-reports of drug use.

Sexual and drug use behaviors among female crack users: a multi-site sample.

The purpose of this paper was to compare female crack users who report exchanging sex for drugs and/or money with female crack users who did not report exchanging sex for drugs and/or money. A multi-site sample of (n = 4667) female crack users who participated in the National Institute of Drug Abuse (NIDA) AIDS Cooperative Agreement Project from 20 sites were interviewed. Statistical analysis compared two groups on selected variables of interest: women crack users who reported exchanging sex for drugs and/or money (n = 2658) and women crack users who did not report exchanging sex (n = 2009). Results indicated that both groups of women had frequent unprotected sex. However, women who exchanged sex had more sexual partners, had sex more often, used drugs before and during sex more often, and had a higher rate of STDs than women who did not exchange sex. In addition, African-American women, homeless women, and women who reported past substance abuse treatment were about twice as likely to exchange sex. Regional differences were also examined.

Differences in young adult psychopathology among drug abstainers, experimenters, and frequent users.

Shedler and Block offered the provocative proposal that individuals who experiment with drugs are psychologically healthier than either those who abstain completely or those who are frequent users. Not all studies have come to such conclusions, however. In an effort to specify under what conditions Shedler and Block's conclusions might hold, the present study examined three groups of drug users (abstainers, experimenters, frequent users) classified according to three different criteria: (a) marijuana use at age 20; (b) alcohol use during 10th grade; and (c) alcohol use at age 20. The three groups were compared at age 20 in terms of personality, deviant behavior, and psychopathology. The results revealed that abstainers were never more psychologically impaired, and were occasionally healthier, than experimenters. Frequent users of marijuana were consistently more imparied than both the abstainers and experimenters, in terms of both internalizing and externalizing disorders. Classification according to marijuana use appeared to be more related to psychopathology than did classification according to alcohol use.

Case management and behavioral contracting. Components of rural substance abuse treatment.

This article presents a model of case management with rural clients entering drug and alcohol treatment. As part of a larger treatment protocol called Structured Behavioral Outpatient Rural Therapy, behavioral contracting is combined with strengths perspective case management to help rural clients motivate themselves to engage and complete drug and alcohol treatment. This combined approach is designed to continually communicate and teach an "A-B-C" cognitive-behavioral approach to problem-solving and change. While not a panacea for addressing the myriad problems facing clients with drug use problems, such an approach promises to improve "treatment as usual" formats, which often ignore the formidable obstacles to human change experienced by rural clients and clinicians.

Project DARE: no effects at 10-year follow-up.

The present study examined the impact of Project DARE (Drug Abuse Resistance Education), a widespread drug-prevention program, 10 years after administration. A total of 1,002 individuals who in 6th grade had either received DARE or a standard drug-education curriculum, were reevaluated at age 20. Few differences were found between the 2 groups in terms of actual drug use, drug attitudes, or self-esteem, and in no case did the DARE group have a more successful outcome than the comparison group. Possible reasons why DARE remains so popular, despite the lack of documented efficacy, are offered.

Primary socialization theory and a bio/psycho/social/spiritual practice model for substance use.

This article supports primary socialization theory as a theory for practitioners to use in drug-user treatment and prevention interventions. Primary socialization theory is compatible with the bio/psycho/social/spiritual practice model and targeting the individual within his or her etiological domains/situation to initiate specific interventions. Governmental institutions are posited as an additional secondary socialization factor for primary socialization theory. Gender is stressed as important for primary socialization theory and is emphasized for carrying out interventions. [Translations are provided in the International Abstracts Section of this issue.]

Risky sex behavior and substance use among young adults.

Many young adults, despite widespread prevention and education efforts that target this age group, engage in behaviors that place them at risk of HIV infection. These behaviors include frequent experimentation with alcohol and other drugs before sex, sexual activity with different partners, and inconsistent safe-sex practices. The combination of these risky behaviors causes increased concern about the spread of HIV among this age group. The study discussed in this article examined the relationship between substance use during adolescence and HIV risk behavior among young adults ages 19 to 21 with and without a college education. Results indicated that increased use of alcohol and marijuana at younger ages is related to riskier sexual activity and increased use of alcohol and marijuana as young adults. Recommendations for interventions are made.

PIP: A mailed survey was conducted to assess the risky sexual behavior and substance abuse among an initial sample of 2071 young adults in Lexington, Kentucky, during the 1987-88 school year. The survey included specific items about peer relations, family attachment, self-esteem, sensation seeking, friends' drug use, impulsivity, physical health, health and mental health utilization, dieting, delinquency, violence, and risky sexual behavior. A total of 952 (400 males and 552 females) respondents were included in the final analysis. The findings indicate that earlier initiation of sexual activity is related to early involvement with drugs. Furthermore, male participants who used alcohol or marijuana at a younger age engaged in riskier sexual behavior than female participants. Female participants were more likely to use condoms regardless of their early substance use patterns; and those who had never experienced sex or who initiated sex later (ages 19 or 20) were less likely to report lifetime or current drug use. This study indicated that there is a relationship between the early occurrence of substance use and riskier sexual behavior. Recognizing the use of alcohol or marijuana during adolescence may raise practitioners' awareness, helping them identify HIV risk behavior among young adults more accurately.