Religiosity and sexual risk behaviors among African American cocaine users in the rural South.

Human immunodeficency virus (HIV) among African Americans has been at epidemic levels for more than 2 decades.1 Incidence of HIV and other sexually transmitted infections (STIs) is significantly higher among African Americans than among whites.2 For example, while in 2010 only 12% of the US population was African American, African Americans represented 44% of new HIV infections in the United States.3 This disparity is especially large in the southern United States.4 High-risk sex is the primary route of HIV transmission among African Americans, and noninjection drug use is a major contributing factor to participation in risky sexual behaviors and to disproportionate HIV and STI rates.2 Thus, African American drug users are at especially high risk for HIV and other STIs. Due to the need to address these disparities and the importance of religion within many rural, Southern, and African American communities, there have been calls for faith-based elements to be incorporated into sexual risk reduction efforts for these communities.5–7 A limited number of qualitative studies have begun to explore the importance of religion in the lives of African Americans who use drugs living in the rural South. This work found that despite potential stigmatization, rural Southern African Americans who use drugs rely on their religious beliefs and local religious institutions for intangible and tangible support; they appear to be as religious as their non–drug using counterparts in terms of expressions of faith, connection to God, and the use of prayer and other forms of private religious practice.8,9 These studies have also found that drug use may limit their participation in public religious activities and may result in ostracism from church-based social networks, social support, and other avenues by which religion has been hypothesized to affect health behaviors.6,8,10 Furthermore, previous research has shown the protective influence of religion against the initiation of substance use, the development of substance abuse disorders, the receipt of substance abuse treatment, and other HIV-related substance use risk behaviors.11–13 Several dimensions of religion have also been associated with HIV-related sexual risk behaviors, including increased HIV testing, fewer sexual partners, and higher self-efficacy in refusing risky sexual encounters and discussing HIV prevention.14–16 With a few noteworthy exceptions,17–20 much of the sexual risk and religion research has been among adolescents and not among at-risk adults. Few quantitative studies have examined religion’s association with sexual risk behavior among substance abusing adults who are not currently receiving counseling or treatment. One reason for this hesitancy may be that research involving religion has been extensively criticized due to poor operationalization of religious constructs and the use of unreliable measures.6,21,22 Researchers in this area have been encouraged to use increased specificity in their description and measurement of individual heterogeneous dimensions of religion and to avoid collapsing separate religion variables.21,23 Similarly, sexual risk researchers have recommended increased specificity in the measurement of sexual behaviors.24–26 Although the number of unprotected sex acts is the recommended self-report behavior for HIV prevention research among at-risk heterosexuals,27 there are numerous other sexual behaviors that can increase STI risk including multiple sexual partners, transactional sex, incorrect condom use, and substance use before or during sex. Whether assessing religious behaviors or sexual behaviors, specific and thorough measurement is critical to advancing the field. In fact, the relationship between religion and sexual behavior may differ depending on the exact religion and sexual behaviors being measured. It is possible that the mixed results in the literature on risk behavior and religion are related to a failure to account for these issues.18,19,28 The aim of this exploratory study was to examine the relationship between well-defined dimensions of religion and specific sexual behaviors within an understudied at-risk population, African Americans who use cocaine living in the rural southern United States. Based on community input and the limited body of empirical evidence, we hypothesized that among our study participants: (1) positive religious coping; private and public religious participation; and God-based, congregation-based, and church leader-based religious support would be inversely associated with at least 1 sexual behavior (ie, less unprotected sex, fewer sexual partners, less substance use before or during sex, fewer sexual encounters, or less transactional sex); (2) negative religious coping would be positively associated with at least 1 sexual behavior (ie, more unprotected sex, more sexual partners, greater substance use before or during sex, more sexual encounters, or more transactional sex); and (3) religious preference would not be associated with sexual behavior due to lack of variation in the sample.