Drug Use and HIV Risk in Alaska Natives

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Alaska Natives have been done (Davidson, Kaplan, Hartley, Lair more, & Lanier ... FISher, Dennis G., Henry H. Cagle, and Patricia J. Wilson. Co-published ...
Drug Use and HIV Risk in Alaska Natives Dennis G. Fisher, PhD

Henry H. Cagle, BS

Patricia 1. Wilson, MSN

Little has been published about Alaska Natives or American Indians and their risk for Human Immunodeficiency Virus (HIV) (Estrada, Erickson, Stevens, & Fernandez, 1990; Rowell, 1990). Some small exploratory studies of HIV seroprevalence among Alaska Natives have been done (Davidson, Kaplan, Hartley, Lair­ more, & Lanier, 1990; Robert-Guroff et aI., 1985), but no published behavioral studies. There has been a report that intravenous cocaine and amphetamine use was the major route of transmission in an Dennis G. Fisher is Director of the Center for Alcohol and Addiction Studies at University of Alaska Anchorage. Henry H. Cagle and Patricia J. Wilson are also arriliated with the Center for Alcohol and Addiction Studies. Appreciation for assistance with this project is gratefully given to Mark John­ son, Alice Baer, Sherry Donnelly, Dawn Davis, Ken Brooks, Mont Hadley and Grace Reynolds. This research was supported in part by grant number 1 UOI DA07290 from the National Institute on DlUg Abuse. Requests for reprints should be sent to Dennis G. Fisher, Center for Alcohol and Addiction Studies, University of Alaska Anchorage, 32 J 1 Providence Drive, Anchorage, AK 99508. [Haworth co-indexing entry note]: "Drug Use and illY Risk in AJaska Natives." FISher, Dennis G., Henry H. Cagle, and Patricia J. Wilson. Co-published simultaneous­ ly in Drngs & Society (The Haworth Press, Inc.) Vol. 7, No. 3/4, 1993, pp. 107-117; and: AIDS and Community-Based Drng Intervention Programs: Evaluation and Out­ reach (ed: Dennis G. Fisher, and Richard Needle) The Haworth Press, Inc., 1993, pp. 107-117. Multiple copies of this article/chapter may be purchased from The Ha­ worth Document Delivery Center [1-800-3-HAWORTH; 9:00 am - 5:00 pm. (ESnl. © 1993 by The Haworth Press, Inc. All rights reserved.

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epidemic of hepatitis B among American Indians (Harding, Helger­ son, & Damrow, 1992). The fust paper published on intravenous drug use (lVDU) in Alaska concluded that Alaska has a major problem with IVDU and that this could be an important vector of HIV transmission into the non-lVDU population of the state (Fish­ er, Wilson, & Brause, 1990). A recent master's thesis (Tarrant, 1992) found that Blacks, Natives, and Hispanics were overrepre­ sented in a sample of community health outreach worker contacts of IVDUs and their sex partners. Also reported was the fmding that Alaska Native IVDUs were younger than other ethnic groups. Tar­ rant suggested this indicates that drug use is a recent phenomenon in the Native community. Conway, Hooper, and St. Louis (1989) found that HlV seroprev­ alence is higher for Native Americans than the cumulative inci­ dence of AIDS in this group. They suggest that there is either: widespread racial misclassification, or more recent entrance of HIV into this population. The concern about IVDU among the American Indian/Alaska Native (AI/AN) group derives from the high levels of drug use among this group, and the frequency of their high risk behaviors (Conway et aI., 1992; Estrada et al., 1990; Fisher & Booker, 1990; Rowell, 1990). These concerns may be validated by reports that the increase in diagnosed AIDS cases from 1989 to 1990 was higher among the AI/AN group than any other ethnic group (Melter, Con­ way, & Stehr-Green, 1991).

FEMALE SPECIFICS In general, women are the fastest growing group of people with AIDS (Shayne & Kaplan, 1991). In particular, those who are poor and are ethnic minorities have been afflicted. There are two pre­ dominant routes by which women in America are becoming in­ fected with HIV. The fust is through lVDU, and the second is by having unprotected sex with an infected maIe lVDU (Cohen, Hauer, & Wofsy, 1989; Des Jarlais, Chamberland, Yancovitz, Weinberg, & Friedman, 1984). Klee, Faugier, Hayes, Boulton, and Morris (1990) found that injection drug users who share their injection equipment are less likely to use condoms than non-sharing injectors. The fe­

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Fisher. Cagle. and Wilsoll

dians (Harding, Helger­ Iblished on intravenous at Alaska has a major an important vector of ation of the state (Fish­ laster's thesis (Tarrant, panics were overrepre­ 'each worker contacts of ed was the fmding that ther ethnic groups. Tar­ IS a recent phenomenon

male sex partners of injection drug users have been the subject of some attention and increased risk has been observed for Black female sex partners of injection drug users (Corby, Wolitski, Thornton -J ohnson, & Tanner, 1991). The risk behav iors of AI/AN women have not been as well investigated as those for Black women. Melter and Stehr-Green (1990) report that the distribution of Ac­ quired Inunune Deficiency Syndrome (AIDS) cases for the Al/AN group is unique in that it is the only ethnic group that has more female than male IVDUs. Other ethnic groups have consistently reported more male than female drug users in a variety of studies, but Beauvais, Oetting, Wolf, and Edwards (1989) appear to corroborate the notion of equal sex ratios of drug users among Al/AN in that their data show that female subjects use drugs at the same rate as the male subjects.

lund that HIV seroprev­ U1 the cumulative inci­ ~st that there is either: , recent entrance of HIV ,merican Indian/Alaska ligh levels of drug use leir high risk behaviors Fisher & Booker, 1990; iated by reports that the 189 to 1990 was higher nic group (Melter, Con­

:S g group of people with lar, those who are poor ed. There are two pre­ erica are becoming in­ J, and the second is by £YDU (Cohen, Hauer, & "ancovitz, Weinberg, & hon, and Morris (1990) ,eir injection equipment aring injectors. The fe-

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METHOD

Subjects

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Subjects were recruited within the Municipality of ~chorag~ Alaska using a targeted sampling strategy (Watters & Biernacki, 1989). The data collection took place from October 1991 through April 1992, at the Drug Abuse Research Field Station (DARFS) in Anchorage, Alaska. In order to be eligible for the study a subject had to: (a) be eighteen years of age or older, (b) test positive fo~ either cocaine, morphine, or amphetamine on a urine test (Roche Diagnos­ tics), and/or (c) present visible "track" marks indicative of recent injection drug use, and (d) not have been in drug or alcohol treatment within the last 30 days.

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The major data collection instrument was the Risk Behavior As­ sessment (REA). This instrument focuses on high risk behaviors for HIV. It has been subject to extensive reliability testing (Needle et al., 1992). A supplemental questionnaire was also used. This supplemen­

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tal questionnaire asked about dates of first injection, locations of first and last injection (city and state), and drug of choice.

RESULTS There are 352 interviewees of whom 62 (17.33%) are self-identi­ fied Alaska Natives. Figure 1 shows the ethnic distribution of our sample (labeled DARFS) in comparison with the overall ethnic distribution of the Municipality of Anchorage (Fison et aI., 1991). Whites and Asians are underrepresented in our sample, whereas Blacks and Natives are overrepresented. Over 95% of all interview­ ees reported that their sexual preference is heterosexual. The Alaska Natives (M = 30.67 years) are significantly younger than the non­ natives (M = 34.97 years) /(93.2) = 4.64, P = .0001. There is a greater proportion of female interviewees among the Alaska Na­ tives than there is for the other two ethnic groups x2(1, N = 352) = 12.746, P = .000. There are almost equal numbers of female and male Alaska Natives in the sample. The Alaska Natives reported having significantly lower income than the non-natives /(87.7) = 1.99, P = .049. As measured on an ordinal scale of 8th grade, less than high school, GED, high school graduate, trade school, some college, and college graduate, the Alaska Natives are significantly lower than the other two ethnicities (Kruskal-Wallis approximation) x2(2) =25.718, P = .0001. When asked the question "Has a doctor or a nurse ever told you that you have had hepatitis B?" the Alaska Natives are significantly more likely to report in the affirmative than non-natives x2(1, N = 351) = 6.889, p = . 009. When route of administration (intravenous, or smoking) is ex­ amined by ethnicity, it is apparent that Blacks are significantly more likely to be smokers, whereas Whites and Natives are about equally split between smoking and injection drug use x2(2, N = 350) = 75.833, P = .000. Of the 62 Alaska Natives in the sample, 39 report that they have never injected drugs. When asked "Where were you when you first shot drugs?" 29 of the Alaska Natives report that they were in Alaska, 3 in California, 2 in Washington state, and one each in New Mexico, Ohio, Oregon, Japan, and VietNam. Of those who reported that they were in Alaska, 25 said that they were in

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Anchorage, and one each in Fairbanks, Kodiak, McGrath, and Pe­ tersberg. When asked "Where were you when you last shot drugs?" 34 of the Alaska Natives report that they were in Alaska, and one each in California, Oregon, and Washington state. When asked where they were right before they came to Alaska, five report California, two Hawaii, and one each in Arizona, Kansas, New York, Oklahoma, and Washington state. Twenty-nine of the Alaska Natives report that their drug of choice is cocaine, three report heroin, two other opiates, and three other drugs. . There are more Alaska Native injectors who are female than male. Both Blacks and Whites have several times more male as compared to female injectors .x2(2, N =108) =9.463, P =.009. The reversal of this gender relationship is noteworthy. The mean number of sex partners in the last 30 days is lower for the Alaska Natives than it is for the non-natives, but not significant­ ly so. The number of sex partners in the last 30 days who were drug injectors is significantly higher for the Alaska Natives (M =0.79) as compared to the non-natives (M = 0.38) (59.6) = 2.07, P = .0428. The reason why these means are less than unity is because they include respondents who did not have sex with drug injectors. When the number of sex partners in the last 30 days who were drug injectors is used as the numerator, and the total number of sex partners in the last 30 days is used as the denominator, the quotient is the percent of sex partners in the last 30 days who were drug injectors. This value, percent of sex partners who were injectors, was used as a dependent variable in a two-way full factorial ANO­ VA. We used PROC GLM type III sums of square because of unequal cell sizes (SAS Institute Inc. [SAS], 1988). Interviewees who reported abstinence in the last 30 days were deleted from the analysis. There is a main effect of ethnicity F(2, 259) = 12.60, P = .001, but neither is there a main effect of sex, nor an ethnicity by sex interaction. Referring to Figure 2 it is clear that the Blacks are significantly lower than the other two ethnicities. It is also notewor­ thy that, by far, the group with the highest percentage is the female Alaska Natives. Examining just the female Alaska Native interviewees, a com­ parison of injectors with smokers shows that, as expected, the injec­ tors (M = 57.9%) have a higher percentage of injecting sex partners

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Kodiak, McGrath, and Pe­ when you last shot drugs? " y were in Alaska, and one ington state. When asked me to Alaska, five report in Arizona, Kansas, New Twenty-nine of the Alaska :e is cocaine, three report , r drugs. :tors who are female than ~veral times more male as L08) = 9.463, p = .009. The teworthy. he last 30 days is lower for natives, but not significantlast 30 days who were drug laska Natives (M = 0.79) as ) 1(59.6) = 2.07, P = .0428. than unity is because they e sex with drug injectors. last 30 days who were drug d the total number of sex e denominator, the quotient 1st 30 days who were drug ll1Jlers who were injectors, No-way full factorial ANOurns of square because of [SAS], 1988). Interviewees days were deleted from the icity F(2, 259) = 12.60, p = : sex, nor an ethnicity by sex s clear that the Blacks are hnicities. It is also notewor­ est percentage is the female

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