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The role of prisons in the HIV epidemic among female injecting drug users.

The objective of this study was to describe factors associated with imprisonment of female injecting drug users (IDUs) and to assess if female IDUs who have been in prison have different HIV risk behaviours when compared to females IDUs who have never been incarcerated. A seroepidemiological survey was conducted of 304 female IDUs recruited in outreach and treatment programmes in Madrid, Spain. Data on sociodemographic characteristics and recent and lifetime risk factors, sexual and reproductive history and history of imprisonment were collected. Bivariate analysis and a logistic regression model were used to identify factors associated with imprisonment. Risk factors for imprisonment were having illegal sources of income, not having a fixed address, leaving education before finishing primary school and starting injection of drugs early in adolescence. HIV risk behaviours were highly prevalent among this population of female IDUs and drug injection in prison was reported by more than one-third of those who had ever been imprisoned. In addition, recent HIV risk behaviour indicators were not associated with imprisonment, suggesting that incarceration did not lead to risk reduction after release from prison. Female IDUs who have been in prison have substantial reproductive health problems that require gynaecological care. These results point to the urgent need for prevention programmes which address HIV and other blood-borne infections using gender specific approaches for women IDUs incarcerated in Spanish prisons.

Determinants of HIV prevalence amongst female IDU in Madrid.

OBJECTIVE: To explore the multitude possible factors associated with HIV in a population of female injecting drug users (IDUs) in Madrid, Spain. DESIGN: A cross-sectional study was undertaken and because of the lack of sampling frame in this population, a convenience sample was recruited from drug treatment, methadone services and street settings. METHODS: Face to face interviews were conducted with 304 female IDUs during October 1995-March 1996. HIV status was determined from antibody testing of blood samples or from written confirmation of HIV test results from a physician. A hierarchical logistic regression model was used to identify direct and indirect relationships with HIV prevalence. RESULTS: HIV prevalence in the sample of female IDUs for which HIV status was known (n = 262) was 63%. Factors independently associated with HIV prevalence in the regression analysis included: having a regular HIV positive sexual partner [odds ratio (OR): 12.2], age over 34 years (OR: 3.4), no fixed address (OR: 2.9), co-infection with a sexually transmitted infection (STI) in the last year (OR: 2.8) and ever shared needles (OR: 2.6). CONCLUSIONS: The documentation of the context of risk behaviour in female IDU is important to predict the course of the epidemic and to develop prevention strategies. The sexual partners of female IDUs in Spain are important components in explaining the HIV epidemic in this population as other risk factors, including high risk drug taking behaviour. The findings also highlight the need to target homeless IDUs women and inmate women with outreach services offering preventive interventions. More effective STI prevention and control strategies are also warranted.

Women, drugs and HIV/AIDS: results of a multicentre European study.

BACKGROUND: In the light of rising human immunodeficiency virus (HIV) incidence rates amongst women in Western Europe, a multicentred, cross-sectional study was undertaken to explore the multitude of possible factors associated with HIV in a population of female injecting drug users (IDU). METHODS: Face-to-face interviews were conducted with 1198 female IDU recruited from a variety of settings in Paris, Madrid, Rome, London and Berlin. Their HIV status was determined from antibody testing of blood or saliva samples or from written confirmation of HIV test results from a physician. A hierarchical logistic regression model was used to identify direct and indirect associations between socioeconomic factors, marginalization and risk behaviour with HIV prevalence. RESULTS: The HIV prevalence in the sample of female IDU was 27.8% (range: 1.4% in London and 52.6% in Madrid). Factors independently associated with HIV prevalence in the regression analysis included: age >25 years (OR = 2.0-2.9), left full-time education before age 14 (OR = 2.4), no fixed address (OR = 2.2), previous imprisonment (OR = 1.4), commercial sex (OR = 1.3), having a regular HIV positive sexual partner (OR = 6.6), ever shared needles (OR = 1.5) and any sexually transmitted disease (STD) infection in the last year (OR = 1.7). CONCLUSIONS: The sexual behaviour and partners of female IDU in Western Europe are as important a component in explaining the HIV epidemic in this population as other risk factors, including high-risk drug taking behaviour. Homeless IDU women may be an important residual risk group warranting future preventive interventions and women with a history of STD should be a particular target for health education. Differences in HIV prevalence across cities are very large and may be related to differences in harm reduction policies.

A demographic and health survey of Spanish female sex workers: HIV prevalence and associated risk factors.

In order to examine the prevalence of HIV infection and associated risk factors amongst Spanish female prostitutes a multicentre (n = 22) cross-sectional study was conducted between November 1989 and January 1991. Data collected included socioeconomic characteristics, sexual behavior and health status together with blood samples. A total of 1633 prostitutes were recruited into the study. Of these, 1433 (87.8%) consented to blood samples being taken and 180 (12.6%) were HIV positive. HIV seroprevalence was 54.7% for intravenous drug users (IVDUs) versus 3.7% for non-IVDUs. Previous imprisonment, hepatitis B and a partner who was an IVDU were significant predictors of HIV infection according to multivariate logistic regression models.

The prevalence of serological markers for syphilis amongst a sample of Spanish prostitutes.

The results of a multicentre study of 1668 Spanish prostitutes are described with regard to syphilis infection. For those women who permitted serological tests (n = 1095), 30.59% (confidence interval (CI): 30.55%-30.63%) were positive for markers indicating current or prior infection. After adjustment was made for other variables, a significant association with syphilis infection was observed for periods of exposure (i.e. age and years working as a prostitute). No significant associations were detected for either intravenous drug use, or educational attainment. The results of this study are similar to those of some other investigations into the prevalence of syphilis amongst prostitutes.

[Risk behaviors for HIV transmission among the recent clients of a syringe-exchange program in Madrid, 1993]. / Conductas de riesgo para transmisión del VIH entre los usuarios recientes de un programa de intercambio de jeringas en Madrid, 1993.

OBJECTIVE: To determine the prevalence of the major risk behavior in HIV transmission (syringe sharing and failure to use condoms) and associated factors among drug injectors recruited for a syringe exchange program (PIJ) in the city of Madrid. METHODS: Cross-section study. All the information was obtained in 1993 through structured interviews with 441 users who had injected drugs during the previous month and had resorted to the PIJ five times, at most. The reference period for drug use and risk behaviour was the month prior to the interview. The statistical analysis included bivariate methods and logistical regression techniques. RESULTS: 29.2% shared syringes (18% passing and 21.7% taking used syringes) and of those that had sexual intercourse (49.4%), 42.5% always used a condom. 89.5% had an HIV antibody test and of those that knew the results, 48.6% were HIV-positive. Multivariate analysis showed that the association between certain behaviour patterns was significant; i.e., taking used syringes and: passing used syringes (odds ratio -OR- = 6.1; 95% confidence interval -CI- = 3.0-12.5), being HIV-positive (OR = 4.1; CI = 1.8-9.1), being unaware of HIV antibody test status (OR = 4.2; CI = 1.7-10.2) and having used intravenous drugs for 5-9 years (OR = 2.9; CI = 1.1-7.9); the association was significant between passing used syringes and: using a mixture of heroin and cocaine (OR = 2.7; CI = 1.1-6.4) and being unaware of HIV antibody test status (OR = 2.5; CI = 1.1-6.0). In the sample as a whole, the association between not using condoms ever and consuming cocaine (OR = 1.7; CI = 1.1-2.9) or crack (OR = 3.0; CI = 1.5-5.9) was significant; furthermore, among those that had sexual intercourse, the association was significant between not using condoms ever and: having been in jail (OR = 2.9; CI = 1.3-6.4), injecting drugs 2-4 times a day (OR = 2.4; CI = 1.0-5.8), having sexual intercourse with drug injectors (OR = 2.6; CI = 1.2-5.9) and having intercourse with two or more partners (OR = 0.4; CI = 0.2-0.9). CONCLUSIONS: The prevalence of HIV infection and risk behavior in the transmission of this virus remain high among drug injectors in Madrid. The habit of sharing syringes is still common, especially among HIV-positive drug injectors (a high percentage take used syringe) and among those who are unaware of their HIV antibody test status. The use of condoms is less frequent among those who have sexual intercourse with other drug injectors or with only one partner.

El VIH y las trabajadoras sexuales / HIV and female sex workers

En esta revisión de las investigaciones publicadas sobre la infección por el virus de la inmunodeficiencia humana (VIH) y los factores de riesgo entre trabajadoras sexuales, se sintetizan los resultados de estudios de seroprevalencia efectuados en distintos países y se analizan los diferentes patrones de transmisión entre dichas trabajadoras en diversas zonas geográficas. Las tasas más altas de infección por el VIH se producen en la zona subsahariana del Africa, donde la amplia difusión de enfermedades de transmisión sexual puede contribuir de manera importante a perpetuar la transmisión. En Europa y América del Norte el uso de drogas inyectadas sigue siendo el factor que más se asocia con la infección por el VIH entre las trabajadoras sexuales, mientras que en America Latina y partes del Asia se observa un patrón mixto de transmisión por contacto heterosexual e inyección de drogas. La presente revisión también abarca estudios sobre los factores de riesgo asociados con la infección por el VIH entre las trabajadoras sexuales, factores que incluyen el consumo de drogas, el comportamiento sexual, la presencia de enfermedades de transmisión sexual y el empleo de condones. Se examinan, además, algunos estudios realizados en clientes de trabajadoras sexuales. Por último, se proponen directrices para futuras investigaciones en esta área y se examinan las diversas intervenciones que hay que realizar para reducir la transmisión del VIH entre las trabajadoras sexuales

HIV and female sex workers.

In this review of published findings on human immunodeficiency virus (HIV) infection and risk factors among female sex workers, we summarize the results of seroprevalence studies in different countries and discuss the different patterns of transmission among such workers in various geographical regions. The highest rates of HIV infection occur in sub-Saharan Africa, where the widespread existence of sexually transmitted diseases may play an important role in sustaining transmission. In Europe and North America injecting drug use continues to be the major factor associated with HIV infection among female sex workers, while in Latin America and parts of Asia there is a more mixed pattern of heterosexual and parenteral transmission from injecting drug use. Reviewed also are studies of the risk factors associated with HIV infection among female sex workers, such as drug use, sexual behaviour, the presence of sexually transmitted diseases, and condom use; in addition, we comment on some studies of the clients of sex workers. Finally, we propose directions that future research in this area might take and discuss various interventions that need to be undertaken to reduce HIV transmission among female sex workers.

El VIH y las trabajadoras sexuales / HIV and female sex workers

En esta revisión de las investigaciones publicadas sobre la infección por el virus de la inmunodeficiencia humana (VIH) y los factores de riesgo entre trabajadoras sexuales, se sintetizan los resultados de estudios de seroprevalencia efectuados en distintos países y se analizan los diferentes patrones de transmisión entre dichas trabajadoras en diversas zonas geográficas. Las tasas más altas de infección por el VIH se producen en la zona subsahariana del Africa, donde la amplia difusión de enfermedades de transmisión sexual puede contribuir de manera importante a perpetuar la transmisión. En Europa y América del Norte el uso de drogas inyectadas sigue siendo el factor que más se asocia con la infección por el VIH entre las trabajadoras sexuales, mientras que en America Latina y partes del Asia se observa un patrón mixto de transmisión por contacto heterosexual e inyección de drogas. La presente revisión también abarca estudios sobre los factores de riesgo asociados con la infección por el VIH entre las trabajadoras sexuales, factores que incluyen el consumo de drogas, el comportamiento sexual, la presencia de enfermedades de transmisión sexual y el empleo de condones. Se examinan, además, algunos estudios realizados en clientes de trabajadoras sexuales. Por último, se proponen directrices para futuras investigaciones en esta área y se examinan las diversas intervenciones que hay que realizar para reducir la transmisión del VIH entre las trabajadoras sexuales

Se publica en inglés en Bull. WHO. Vol. 71(3/4), 1993

[Prevalence of HIV-1 and other sexually transmitted diseases among Spanish prostitutes]. / Prevalencia de VIH-1 y otras enfermedades de transmisión sexual en prostitutas españolas.

BACKGROUND: Many studies in Western countries point to the high prevalence of HIV infection in groups of prostitutes especially among those using intravenous drugs (IVDA). Furthermore, there appears to be a low but increasing number of heterosexually infected prostitutes. METHODS: A cross-sectional study was carried out in a sample of 374 prostitutes selected by collaborating groups in 11 provinces with the aim of studying the prevalence of HIV and its associated risk factors in Spanish prostitutes. Furthermore, the prevalence of other sexually transmitted diseases (HIV-2, HTLV-I/II, hepatitis B and syphilis), the frequency of different sexual activities and the use of condoms were investigated in this group. The data were collected by interview using a previously tested questionnaire. RESULTS: Serological analysis demonstrated that 54 persons were positive for HIV-1 (16%), none for HIV-2, 1 for HTLV-I/II, 113 for hepatitis B (46%) and 84 for syphilis (25%). The main risk factor for HIV infection was IVDA; 60% of this group was positive vs 3% of the non IVDA (OR = 47.6; confidence interval 18.4-128.0). Consistent condom use in this population is low, although it varies according to the type of relation and sexual partner. Forty-nine percent of the women having vaginal relations with their customers reported using condoms at all times or almost all times vs 36% for anal relations and 22% for oral relations. These percentages were reduced to 10%, 6% and 3%, respectively with private sexual partners. CONCLUSIONS: Studies concerning HIV prevalence and its associated risk factors in Spanish prostitutes should be continued in order to monitor trends in HIV infection and the use of protective measures.