HIV prevention needs of sex-trading injection drug-using black men who have sex with both men and women.

As of 2007, a paucity of research exists that explores factors that may be useful for developing HIV prevention programs targeted toward sex-trading injection drug–using men who have sex with both men and women (IDU-MSM/W). For the purpose of this study, IDU-MSM/W refers to injection drug using men who have sex with both men and women, and who trade sex for drugs and/or money to purchase drugs. Many studies of HIV infection that included injection drug users (IDUs), since 1991, have focused on whether injection or sexual risk factors, or both, were associated with HIV seroconversion, and have not included sexually transmitted diseases (STDs; Bluthenthal, Kral, Erringer, & Edlin, 1999; Kral, Bluthenthal, Lorvick, & Gee, 2001; Longshore, Bluthenthal, & Stein, 2001). Others have examined risk factors among IDUs (Kral, Bluthenthal, Erringer, Lorvick, & Edlin, 1999; McFarland, Kellog, Dilley, & Katz, 1997; Dushay, Singer, Weeks, Rohena, & Gruber, 2001), and explored the relationship between self-reported sexual orientation and behavior among IDUs (Pathela et al., 2006; Washington et al., 2006). At the end of 2005 (the most recent year for which statistics are available), an estimated 217,323 men who have sex with men (MSM) in the United States were living with AIDS, representing 67% of all men and 52% of all people living with AIDS (Centers for Disease Control [CDC], 2007). In the United States, MSM are still the group at greatest risk: 72% of people diagnosed with AIDS in the United States in 2002 were MSM. In addition, MSM make up the largest group of new HIV cases in men (45%), compared with IV drug users who are not MSM (11%), men who have sex with women (9%), and MSM who inject drugs (3%; CDC, 2007). Little is known about IDU-MSM/W involved in sex trade, a subpopulation of the MSM community. Additionally, evidence exists across numerous surveillance studies that despite HIV/STD prevention efforts, African American IDUs and MSM are still disproportionately affected and infected by HIV and other STDs (Celentano et al., 1991; CDC, 2000; de Luise, Blank, Brown, & Rubin, 2002; Strathdee et al., 1998). According to Pathela, Blank, Seil, and Schillinger (2006), results from a study conducted in New York City suggested that MSM who exclusively had sex with men and self-identified as heterosexual were more likely than their gay-identified counterparts to be an ethnic-minority, foreign-born, had only one sex partner within the last year, yet they were less likely to have been tested for HIV, and less likely to have used a condom during their last sexual encounter. The impact of HIV/AIDS on African American IDU-MSM/W has been greater for some U.S. metropolitan cities (CDC, 2004). For example, African Americans represent 27.9% of the population in the state of Maryland (U.S. Census Bureau, 2001), yet African Americans represent 79.5% of reported AIDS cases in the state of Maryland (CDC, 2003a). A similar disparity exists for the largest city in the state of Maryland: African Americans represented 64.3% of the population in the city of Baltimore, but represented 88% of all reported AIDS cases in the city of Baltimore (CDC, 2003a). Furthermore, intravenous drug use has directly and indirectly accounted for more than one third (36%) of AIDS cases in the United States since the epidemic began (CDC, 2003a). However, in the state of Maryland, IDUs accounted for more than half (53%) of AIDS cases. IDU-associated AIDS cases continue to be an important public health issue. Reports on IDU-associated AIDS cases in the United States and Maryland among MSM in the United States, respectively, accounted for 13% and 3% (CDC, 2003a). There have been significant medical diagnostic and management advances and improved treatment for people living with HIV since the epidemic began, particularly new antiretroviral agents. However, STDs and HIV infection among MSM/W and IDUs remain an important issue, particularly for the African American community. Courtenay-Quirk, Wolitski, Hoff, and Parsons (2003) reported that HIV-seropositive African American MSM had higher interest in programs focusing on safer sex and serostatus disclosure as compared with their White counterparts. Since the beginning of the HIV epidemic, numerous quantitative and qualitative studies have examined MSM/W and the different sexual and drug-use patterns of these men compared with homosexual men (CDC, 2003b; Chu, Peterman, Doll, Buehler, & Curan, 1992; Crawford, Allison, Zamboni, & Soto, 2002; Peterson et al., 1992; Stokes, McKiman, Doll, & Burzette, 1996). However, these studies are limited in providing data concerning the HIV prevention needs specific to the IDU-MSM/W sex-tradecommunity. No study has explored specifically HIV prevention for the African American IDU-MSM/W sex-trade community (Johnson et al., 2005). The MSM/W who are IDU involved in sex trade pose a double concern when engaging in unprotected sex for both their male and female sex partners. Likewise, they put themselves at risk for sexually transmitted infections. The IDU-MSM/W who are on the “down low” (men who do not self-identify as homosexual; however, secretly have sex with other men) may be ashamed and stigmatized for participating in sex with another male, and may subsequently participate in sexual encounters with other men in secret, despite having sex with women. Limited data exist for IDU-MSM/W involved in sex trade concerning HIV prevention needs for this subpopulation. Despite previous research that suggests that MSM/W are more likely to practice safer sex than self-identified homosexual men (Peterson et al., 1992), these studies have provided minimal information about the subpopulation, IDU-MSM/W involved in sex trade. Hence, research is needed that explores prevention needs for IDU-MSM/W, a population involved in high-risk behaviors that are primary and secondary transmission categories (CDC AIDS Community Demonstration Projects Research Group, 1999; CDC, 2007). These men, who are at an increased risk of HIV exposure being IDUs involved in sex trade, require expanded and targeted HIV prevention programs that focus solely on their needs. To this end, research is needed that explores the needs of the IDU-MSM/W, involved in sex-trade community, directly from the viewpoint of the participants. The purpose of this study was to explore the following questions: (a) What kinds of information and materials would be important to include in an HIV prevention program developed for IDU-MSM/W? (b)What issues do IDU-MSM/W perceive to be crucial that need to be addressed in an effort to motivate and increase safer sex practices among them and their male and female sex partners? (c) What is the feasibility of involving recovering IDU-MSM/W as peer educators to take messages to the street as a means of delivering an HIV education intervention to active IDU-MSM/W?