This document summarizes findings from a 2005-2006 study of injection drug users in Dallas, Texas using respondent-driven sampling. Key findings include: - 597 participants were interviewed, most were African American males aged 45-54 with a high school education or less. - High rates of unprotected sex (68%) and drug/alcohol use before or during sex (85%) were reported. - Testing rates in the past year were high for HIV (87%) but lower for HCV (42%) and syphilis (22%). - Prevention service utilization in the past year was high for condoms (84%) but lower for other services like syringe access (30%). - Using drugs/al

1. Substance Abuse, Sexual Behaviors,
HIV/STD/HCV Testing, and Prevention Service
Utilization among Injection Drug Users in
Dallas, Texas, 2005-2006
Shane U. Sheu, MPH,
Sonia Arbona, PhD,
Erin Elbel,
Doug Kershaw,
Praveen R. Pannala, MD, MPH
Sharon K. Melville, MD, MPH
Texas Department of State Health Services
May 25, 2010
1

2. Objectives
 To obtain prevalence estimates using respondent driven
sampling (RDS) among injection drug users in Dallas for
 Substance abuse behaviors
 Sexual behaviors
 Testing behaviors
 Prevention services utilizations
 To explore the relationship between concomitant
substance abuse and
 Unprotected sex
 HIV/STD/HCV testing behaviors
 Prevention service utilizations
2

3. B ackgrou nd

4. Per son s L ivi ng wi th H I V/A I D S and
New H I V/A I D S C ases, Texas,
2002-2008
70,000
60,000 63,019
59,829
56,884
50,000 54,292
51,048
HIV/AIDS Cases
47,776
44,508
40,000
Persons living with HIV/AIDS
New HIV/AIDS cases
30,000
20,000
10,000
5,159 4,483 4,512 4,486 4,112 4,403 4,481
0
2002 2003 2004 2005 2006 2007 2008
Year
Data Source: Texas HIV/AIDS Reporting System (HARS); 2002-2008

5. Propor tion of A I D S C ases by Tran sm i ssion
C ategory, Texas, 1990-2008
70
60 Male-to-male sexual contact (MSM)
50
Cases, %
40
High risk heterosexual contact*
30
Injection drug use (IDU)
20
10
MSM and IDU
0
90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08
Year of Diagnosis
•Heterosexual contact with person known to have or to be at high risk for HIV infection
Data Source: Texas HIV/AIDS Reporting System (HARS); 1990-2008

6. National H I V B ehavioral S u r vei llance
S ystem S i tes
Seattle
Boston
New Haven
Nassau
Detroit New York City
San Francisco Newark
Philadelphia
Chicago Baltimore
Denver Washington, DC
Las Vegas Norfolk
Los Angeles St. Louis
San Diego
Atlanta
Dallas
High risk population cycles: Houston Ft. Lauderdale
• IDU New Orleans Miami
San Juan
• MSM
• Heterosexuals
Source: Centers for Disease Control and Prevention 6

7. Methods

8. NH B S O verall S trategy
 S u rve y co m p o n e n ts
C o re q u e sti o n s
 D e m o grap h i c ch aracteri sti cs
 Alco h o l an d d ru g u se ri sk b e h avi o rs
 S e x u al ri sk b e h avi o rs
 T e sti n g b e h avi o rs: H I V, H C V, sy p h i li s
 Pre ven ti o n servi ce s u ti li z ati o n
L o cal q u e sti o n s tai lo re d to e ach si te
 H I V te sti n g (N o t d o n e i n D allas I D U 1 )
 S am p le si z e
 T arge t = M i n i m u m o f 500 p e rso n s i n te rvi e w e d e ach
cycle
8

9. Respondent D r iven Sampli ng
Recr u i tm ent
 S tu d y te am re cru i te d i n i ti al
p arti ci p an ts (se e d s) th ro u gh
o u tre ach
 S e e d s re cru i te d u p to 3
o th er p arti ci p an ts
 T h o se p arti ci p an ts
re cru i te d u p to 3 o th ers
 D o n e u n ti l sam p le si z e w as
m et
 I n cen ti ve s p ro vi d e d fo r
p arti ci p ati o n an d
re cru i tm en t
 $20 fo r i n tervi e w an d
$1 0 fo r e ach re cru i tm en t
9

10. NH B S I DU1 E ligi bi li ty C r i ter ia
 At le ast 1 8 ye ars o ld
 Re si d e n t o f D allas Fo rt Wo rth M S A
 I n je cte d n o n -p re scri b e d d ru gs i n p ast 1 2
m o n th s
 Vi si b le si gn s o f i n je cti o n an d /o r d e tai le d
k n o w le d ge o f i n je cti o n p racti ce s
 Ale rt an d ab le to co m p le te su rve y i n E n gli sh
o r S p an i sh
10

11. D allas NH B S I DU1 O ver view
 C o n d u cte d i n D allas/Fo rt Wo rth M e tro p o li tan
S tati sti cal Are a (M S A) i n 2005 -2006
 D S H S an d U n i ve rsi ty o f T e x as S o u th w e ste rn
M e d i cal C e n te r
 S i te s i n D allas/Fo rt Wo rth : 5
 C o m p le te d i n te rvi e w s: 597 (1 7 se e d s an d 580
re cru i ts)
11

12. I mplem enti ng R D S at Mu lti ple
S i tes for NH B S I DU1 D allas

13. Stati stical A nalysi s
 We i gh te d p re vale n ce e sti m ate s w i th R D S AT an alysi s
to o l 6.0
 C h i sq u are te st fo r b i vari ate an alyse s o f u n -w e i gh te d
d ata w i th S AS 9.2
13

14. Resu lts

15. NH B S I DU1 D emographic
C haracter i stics
N=597
 G en d er
 M ale 377 (63.1 %)
 Fe m ale 21 5 (36.0%)
 R ace /E th n i ci ty
 Afri can Am e ri can 451 (75.6%)
 W h i te 1 03 (1 7.3%)
 H i sp an i c 30 (5.0%)
 M u lti raci al 1 0 (1 .6%)
Data Source: Texas National HIV Behavioral Surveillance- 2005-2006, IDU1 Data

16. NH B S I DU1 D emographic
C haracter i stics conti nue
 Age G ro u p s N=597
 1 8-24 29 (4.9%)
 25-34 56 (9.4%)
 35-44 1 24 (20.8%)
 45-54 303 (50.8%)
 ≥ 55 84 (1 4.1 %)
 E d u cati o n
 < H i gh S ch o o l 35 (5.9%)
 H i gh S ch o o l o r G E D 427
(71 .6%)
 > H i gh S ch o o l 1 34
Data Source: Texas National HIV Behavioral Surveillance- 2005-2006, IDU1 Data
(22.5%)

17. NHBS IDU1 Recruitment Network of
Participants by Race and Ethnicity
Race and ethnicity
White - homophily 0.401
Afr Am - homophily 0.545
Hispanic - homophily 0.330
Am Indian/Alaska Native -
homophily -1
Multiracial - homophily 0.032
- Most participants recruited
were African American
- Four seeds recruited
the majority of the
participants
Data Source: Texas National HIV Behavioral Surveillance- 2005-2006, IDU1 Data

18. NH B S I DU1 Pr evalence E sti m ates of
Unprotected S ex
N=597
80%
70% 68%
60%
50%
Prevalence
40%
32%
30%
20%
10%
0%
Sex without condom Sex with condom
Data Source: Texas National HIV Behavioral Surveillance- 2005-2006, IDU1 Data

19. NH B S I DU1 Pr evalence E sti m ates of Usi ng
D r ugs or A lcohol before or du r i ng S ex
15%
N=597
85%
Using drugs or alcohol before or while having sex
Not using drugs or alcohol before or while having sex
Data Source: Texas National HIV Behavioral Surveillance- 2005-2006, IDU1 Data

20. NH B S I DU1 Pr evalence E sti m ates of Testi ng
B ehavior s
N=597
100%
90% 87%
80%
69%
70%
Prevalence
60%
Yes
50% No
42%
M/D/R
40% 33%
30% 25%
22%
20%
11% 9%
10%
2%
0%
Ever tested for HIV Ever tested for HCV Tested for Syphilis
in the past 12
months
Data Source: Texas National HIV Behavioral Surveillance- 2005-2006, IDU1 Data

21. NH B S I DU1 Pr evalence E sti m ates of Pr evention
S er vice Uti li zation
N=597
90% 84%
80% 77%
69% 70%
70%
60% 55%
Prevalence
50% Yes
41% No
40% M/D/R
30% 28%
30%
22%
20% 14%
10% 4%
1% 1% 2% 2%
0%
Received Received Received One to One Group
Free Free Sterile Free Drug Counseling Counseling
Condoms Syringes Kits
Data Source: Texas National HIV Behavioral Surveillance- 2005-2006, IDU1 Data

22. NH B S I DU1 Par tici pants Usi ng D r ugs or
A lcohol befor e or du r i ng S ex by Unprotected
S ex
N=597
Sex S e x w i th χ2
w i th o u t
co n d o m co n d o m P valu e
U si n g d ru g o r alco h o l b e fo re
o r d u ri n g se x (n = 522) 80.3% 1 9.7%
< .0001
N o t u si n g d ru g o r alco h o l
30.7% 69.3%
b e fo re o r d u ri n g se x (n = 75)
Data Source: Texas National HIV Behavioral Surveillance- 2005-2006, IDU1 Data

23. NH B S I DU1 Par tici pants Usi ng D r ugs or
A lcohol befor e or du r i ng S ex by S har i ng
I n jection E qu i pm ent
N=597
S h ari n g N o t sh ari n g χ2
i n je cti o n i n je cti o n
equ ip m en t equ ip m en t P valu e
U si n g d ru g o r alco h o l
b e fo re o r d u ri n g se x 78.9% 21 .1 %
(n = 522) 0.01
N o t u si n g d ru g o r alco h o l
66.2% 33.8%
b e fo re o r d u ri n g se x (n = 74)
Data Source: Texas National HIV Behavioral Surveillance- 2005-2006, IDU1 Data

24. NH B S I DU1 Par tici pants Usi ng D r ugs or
A lcohol befor e or du r i ng S ex by S yr i nge
S har i ng
N=597
No χ2
S yri n ge
syri n ge
S h ari n g P valu e
sh ari n g
U si n g d ru g o r alco h o l b e fo re
o r d u ri n g se x (n = 521 ) 54.9% 45.1 %
< .0001
N o t u si n g d ru g o r alco h o l
28.8% 71 .2%
b e fo re o r d u ri n g se x (n = 73)
Data Source: Texas National HIV Behavioral Surveillance- 2005-2006, IDU1 Data

25. NH B S I DU1 O ther F actor s F ou nd Not to be
S tati stically S ign i ficant with Par tici pants
Using D r ugs or A lcohol before or du r i ng S ex
F actors P-valu e
E ve r te ste d fo r H I V 0.29
E ve r te ste d fo r H C V 0.67
T e ste d to ch e ck fo r syp h i li s i n th e p ast 1 2 m o n th s 0.38
R e ce i ve d fre e co n d o m s i n th e p ast 1 2 m o n th s 0.90
R e ce i ve d ste ri le n e e d le s i n p ast 1 2 m o n th s 0.69
U se d fre e n e w ste ri le n e e d le s 0.72
R e ce i ve d fre e k i ts i n th e p ast 1 2 m o n th s 0.85
U se d fre e k i ts 0.32
T alk e d to co u n se lo r o n e o n o n e ab o u t H I V p re ve n ti o n i n th e p ast 1 2 0.53
m o n th s
Parti ci p ate d i n gro u p se ssi o n ab o u t H I V p re ve n ti o n i n th e p ast 1 2 0.81
m o n th s

26. Resu lts S u m m ary
 M ajo ri ty o f N H B S i n je cti o n d ru g u se rs
 H ave se x w i th o u t co n d o m s
 Are h avi n g alco h o l o r d ru gs b efo re o r d u ri n g se x
 H ave te ste d fo r H I V an d H C V i n th ei r li fe ti m e
 N o t te ste d fo r sy p h i li s i n th e p ast ye ar
 N e ver re cei ve d fre e ste ri le n e e d le s, fre e d ru g k i ts, o n e o n o n e co u n se li n g
o r gro u p co u n se li n g ab o u t H I V p re ve n ti o n
 S tati sti cally si gn i fi can t re lati o n sh i p b e tw e e n th o se u si n g d ru g o r alco h o l
b efo re o r d u ri n g se x an d
 U n p ro te cte d se x
 S h ari n g i n je cti o n e q u i p m en t
 S h ari n g syri n ge
 N o stati sti cal si gn i fi can t re lati o n sh i p b e tw e e n th o se h avi n g d ru g o r alco h o l
b efo re o r d u ri n g se x an d
 H I V/S T D /H C V te sti n g b e h avi o rs
 Pre ve n ti o n se rvi ce u ti li z ati o n

27. D ata L i m i tation s
 S e lf-re p o rte d d ata
 T e m p o rali ty o r cau sal re lati o n sh i p can n o t b e
e stab li sh e d
 G e n e rali z ab i li ty
 Afri can Am e ri can s
 D allas vs. T e x as vs. U .S .
27

28. Conclu sion s
 U se o f d ru gs an d alco h o l b e fo re o r d u ri n g se x m ay
i n flu e n ce i n d i vi d u al’s p racti ce o f h i gh ri sk se x u al
b e h avi o r an d i n je cti o n sh ari n g b e h avi o rs
 S u b stan ce ab u se m ay i n cre ase th e p ro b ab i li ty o f
h avi n g u n p ro te cte d se x w h i ch su b se q u e n tly m ay
i n cre ase th e ri sk fo r H I V tran sm i ssi o n am o n g I D U
an d th e i r se x u al p artn e rs
 C o n tact w i th o r u se o f p re ve n ti o n se rvi ce s d o e s n o t
se e m to re d u ce ri sk y b e h avi o rs

29. I mplication s for Program s, Policy,
and Research
 U n d e rstan d i n g ri sk b e h avi o rs am o n g I D U w o u ld
h e lp tai lo r H I V p re ve n ti o n se rvi ce s
 B e tter e d u cati o n fo r I D U s o n h o w H I V i s sp re ad , ei th er
b y o n e o n o n e co u n se li n g an d /o r gro u p co u n se li n g
 E n co u rage co n d o m u se , d i sco u rage d ru g u se , an d
en co u rage u se o f steri le d ru g p rep arati o n e q u i p m en t
an d syri n ge s
 D ata su gge st th e n e e d fo r d e ve lo p i n g e ffe cti ve
p re ve n ti o n strate gi e s to p ro m o te p o si ti ve b e h avi o r
ch an ge
 Pro m o te atten d an ce to p re ven ti o n servi ce o rgan i z ati o n s
 E asy acce ss to p re ven ti o n servi ce o rgan i z ati o n s

30. I mplication s for Program s, Policy,
and Research
 E x p lo re th e fe asi b i li ty o f u si n g re sp o n d e n t d ri ve n
sam p li n g m e th o d
 T o i n cre ase aw aren e ss o f p re ven ti o n p ro gram s
 T o i n cre ase aw aren e ss o f i n je cti o n d ru g u se ri sk
 T o en co u rage te sti n g b e h avi o r

31. References
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D ru g Alco h o l D ep en d . 2 008;95 :54-61 .
2 . H e ck ath o rn , D D . Re sp o n d en t-D ri ven S am p li n g: A N e w Ap p ro ach to th e S tu d y o f H i d d e n Po p u lati o n s. Social
Problems.1 997;44:1 74-1 99.
3. H e ck ath o rn , D D . Re sp o n d en t-D ri ven S am p li n g I I : D e ri vi n g Vali d Po p u lati o n E sti m ate s fro m C h ai n
R eferral S am p le s o f H i d d e n Po p u lati o n s. Soc Problems. 2002; 49:1 1 -34.
ial
4. P u rce ll D W , M i z u n o Y, M e tsch L R , G arfei n R , T o b i n K , K n i gh t K , L atk a M H . U n p ro te cte d S e x u al B e h avi o r
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h e tero se x u al w o m en w i th co n cu rren t se x u al p artn ersh i p s, H o u sto n , T e x as, U S A. I n tern ati o n al J u rn al o f
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6. R i sser JM , Pad ge tt P, Wo lverto n M , R i sser W L . R e lati o n sh i p b e tw e en h e te ro se x u al an al se x , i n je cti o n d ru g
u se an d H I V i n fe cti o n am o n g b lack m en an d w o m e n . I n t J S T D AI D S . 2 009;2 0:31 0-4.
7. Vo lk o w N D , Wan g G J, Fo w ler JS , T e lan g F, J ayn e M , Wo n g, C . S ti m u lan t-I n d u ce d E n h an ce d S e x u al D e si re
as Po ten ti al C o n tri b u ti n g Facto r i n H I V T ran sm i ssi o n . Am J Psych i atry. 2 007;1 64:1 57-1 60.
31

32. A cknowledgem ents
We w o u ld li k e to ack n o w le d ge o u r co lle agu e s at th e
C e n te rs fo r D i se ase C o n tro l an d Pre ve n ti o n , an d
U n i ve rsi ty o f T e x as S o u th w e ste rn M e d i cal C e n te r:
 E li z ab e th A. D i N en n o , Ph D
 M e li ssa C ri b b i n , M PH
 An n e F re em an , M S PH
 D o u glas S h e h an
 O th er U T S o u th w e stern C o m m u n i ty Pre ven ti o n an d
I n terven ti o n U n i t S taff
32

33. T h an k yo u

34. Q uestion s?
S h an e S h e u , M PH
E p i d em i o lo gi st/C o o rd i n ato r
T B /H I V/S T D E p i d em i o lo gy an d S u rvei llan ce B ran ch
H S E S , M ai l C o d e 1 873
T e x as D ep artm en t o f S tate H e alth S ervi ce s
P.O . B o x 1 49347
Au sti n , T e x as 7871 4
Ph o n e : (51 2) 533-3044
S h an e .S h e u @d sh s.state .tx .u s
34