Sex and drug interactions

Female drug users are found in almost all countries, and while the number of female users appears to be increasing, the majority are male, young, and sexually active (Deany, 2000; Reid and Costigan, 2002). Thus men especially serve as a vehicle for HIV spread, not only through unsafe injection practices but also by being a key bridge population for sexual transmission. High-risk sexual behaviors (e.g. multiple sexual partners and sex without a condom) tend to go hand-inhand with more frequent and risky drug use (UNDP, 1999). In many countries, HIV epidemics among injection drug users have been followed by epidemics via sexual transmission among non-injecting populations. Furthermore, in some cases sexual transmission from users to non-injecting partners has become the dominant mode of heterosexual transmission (des Jarlais et al., 1992; Panda et al., 1998). In this regard, drug use is like any other gendered phenomenon. Women are doubly vulnerable, through their own drug use but more frequently through a partner's drug use even when the women themselves are not using. Women may be introduced to drug use by their sexual partners, who actually inject the drugs for them. Some women may fear rejection from their partners if they do not use drugs and, what's more, some use drugs because they believe it will increase their pleasure during sex. Drug use and sexual transmission are especially linked in the countries of Latin American, where cocaine injection predominates. Depending on drug market patterns, crack cocaine (which is not injected) can replace cocaine. Crack has been strongly associated with high-risk sexual behavior and, though not associated with reduced injection-related HIV risk, the overall HIV risk remains high (Calleja et al., 2002; Rossi et al., 2003).

It is also not uncommon for men and women who use drugs to enter into commercial sex work to finance their drug dependence, thus further increasing their risk for HIV transmission (Reid and Costigan, 2002). In a study from North America, 70 percent of female injection drug users and 56 percent of male injectors had exchanged sex for either money or drugs (Rothenberg etal, 2000). There are especially high estimates in places like Russia and the Ukraine, where increasing poverty and unemployment among geographically displaced populations have fueled the spread of sex work (Linglof, 1995; Karapetyan et al, 2002). More recently, female users in a number of Asian countries, including China, Vietnam, the Philippines, Nepal, India, Bangladesh, Pakistan, Indonesia, and Sri Lanka, have become increasingly involved with sex work (Reid and Costigan, 2002). The overlap between injection drug use and commercial sex work serves to increase risk not only at the individual level but also at the population level as different networks interact.

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