Commentary for Li et al., "Sexual transmissibility of HIV among opiates users with concurrent sexual partnerships: An egocentric network study in Yunnan, China."

It has now been 30 years since the Centers for Disease Control and Prevention reported the first case of HIV. In that time, tremendous advances have been made in HIV treatments, care, testing, and prevention. Today, all people of economic means and many without such means have access to life saving HIV treatments. Further, HIV prevention education and practical prevention tools like condoms and sterile syringes are increasingly available. Yet, between 2 and 3 million people will become HIV positive this year, mostly due to unprotected sexual contact. As Li and colleagues remind us, sexual risk is an important component of the HIV epidemic among injection and non-injection drug users.(1) In fact, as early as ten years ago, HIV incidence studies among injection drug users (IDUs) found sex behaviors to be an important independent predictor of seroconversion. (2–4) Further, Li and colleagues highlight the role that multiple concurrent sexual partnerships, particularly in the connection with drug use, can play in the spread of HIV.(1) At the same time, it is hard not to be struck by the clinical terminology and limited approach that characterize much of the research on HIV-related sex risk. It is as though none of us researchers have ever had sex. An important next step in building a more sophisticated, dare we say “real,” approach to sex risk is to consider not merely the sexual preferences and positioning (i.e., tops or bottoms), nor the temporal overlap and sequencing of sexual partners, but to capture the motivations and contexts for this most fundamental human behavior. Important highlights of such an approach include documenting, quantitatively and qualitatively, by partner, the socio-emotional (including intimacy, desire, and pleasure), biological and developmental, economic, and situational factors that drive consensual sexual decision making and behaviors. Recent efforts at the US Centers for Disease Control and Prevention (CDC) and elsewhere in the area of sexual health are speaking to the increased awareness of the need to approach HIV-related sexual risk within a broader and more comprehensive framework.(5, 6) Research on HIV risk and infection among drug users would certainly benefit from this more inclusive and multifaceted approach. An important outcome of this new research must be better targeting of individuals, couples, and groups with interventions that are sensitive and responsive to both limits and opportunities for change within varied sexual relationships as called for by Li and colleagues among others.(1, 7, 8) But it must also include consideration of other social forces that contribute to risk and inhibit protective behaviors as they relate to sex risk among drug users such as economic and social support, law enforcement activities, gender relations, and the multitude of other structural forces that increase sexual risk among drug users. One area where this latter approach has shown promise is in interventions that address the context of sex behavior and risk. Such interventions have been developed most commonly with sex workers, and recognize the complex interplay of economic need, gender norms, sexual desire and pleasure, trust and intimacy, violence, stigma and other factors in which sex work is embedded. (9, 10) A prime example is the Songachi Project -- a successful HIV-prevention intervention that took a comprehensive, rights-based, multilevel approach with sex workers in India. The Songachi Project created a peer education program; offered literacy training (recognizing that education components would not work if women could not read materials); established high level advocates for sex workers; addressed economic barriers (set up a loan program from which sex workers could borrow money in financial crisis situations so that they were not tempted to skip condom use in order to be paid more) and other environmental barriers (e.g., selling condoms rather than giving them away to increase perceived value); changed social relationships not only among sex workers but also between sex workers and key powerful community members, and; built individual HIV/STI prevention and treatment skills.(11) Recent global trends indicate: (1) the continued spread of injection drug use, (12) (2) the increased availability and use of stimulant drugs such as methamphetamine that are likely to lead to an escalation in sex related HIV risk among drug users, (13) and (3) the continued need for more and better HIV prevention intervention and strategies for injecting drug using populations. (14) Moving forward, HIV prevention efforts among drug using populations must focus on sex risk and involve interventions and strategies that address the range of motivations and context of sexual behavior, from those that arise for intimate and emotional factors to those that occur in sex work. And while promising models exist for the latter type of sex risk, new models and approaches are urgently needed to address the much more common sex risk that arise from the human needs for affection, support, child bearing, and physical pleasure among drug using populations.