Abstract This study describes binge use of crack cocaine, binge users, and their sexual risk behaviors in a sample of African-American, HIV-positive users. Fifty-one percent reported a recent crack binge. The typical crack binge lasted 3. Nearly two-thirds reported their last binge was in their own or another's home.
Seventy-two percent had sex during the last binge, with an average of 3. In multivariable logistic regression analyses, recent bingers were more likely than non-bingers to consider themselves homeless, to have any income source, to have used crack longer, and to score higher on risk-taking and need for help with their drug problem.
In multivariable ordinal and logistic regression analyses, recent bingers had more sex partners in the last six months and 30 days and were more likely to have never used a condom in the last 30 days. Among male users, recent bingers were more likely to report lifetime and recent exchange of money for sex and drugs for sex. Among both male and female users, recent bingers were more likely to report lifetime trading of sex for drugs. Further investigations of binge crack use and sexual risk behaviors and interventions targeting and tailored to this group should be considered.
This minority of HIV-positive persons may not only place their sex partners at risk of HIV or other sexually transmitted infections, but may also place themselves at risk for re-infection with medication-resistant HIV strains Booth and Gerretti Studies indicate that HIV-positive persons who use crack cocaine engage in sexual risk behaviors at relatively high rates and may be at especially high risk for HIV transmission or re-infection.
In a study of 10, HIV-positive heterosexual men, heterosexual women, and men who have sex with men, Campsmith et al.
High rates of sexually transmitted infections among crack users may serve to enhance transmission efficiency Fleming and Wasserheit Because HIV-positive crack users are more likely to delay or reduce healthcare utilization Cunningham et al. Moreover, the presence of cocaine in the bloodstream may enhance the HIV replication process Bagasra and Pomerantz ; Roth et al.
Despite the potentially serious consequences of sexual risk behaviors among HIV-positive crack users, the relationship between crack use and sexual risk behaviors is not well-understood. The literature suggests that the relationship between crack smoking and risky sexual behaviors may be explained, in part, by the nature of the high produced by crack use and the subsequent low resulting from crack's withdrawal Williams ; Inciardi et al.
Smoking crack produces a strong sense of euphoria, heightened feelings of mental or physical agility, or other feelings of mood elevation McCoy and Inciardi , increasing expectations of heightened sexual pleasure and reducing expectations of deleterious consequences of behavior Seage et al. Conversely, deprivation of crack may cause anxiety or depression and extreme cravings for the drug, and users experiencing extreme cravings may exchange sex for crack or for money to purchase more crack Williams ; Inciardi et al.
Extending this view about the pharmacologic effects of crack smoking on sexual risk behaviors, the literature also suggests that patterns of crack use influence the frequency and types of sexual risk behaviors. The relationship between crack smoking and risky sexual behaviors was understood in terms of the high and low phases of a binge cycle, and it was assumed that sexual risk behaviors were influenced largely by the intensity and frequency of binge behavior Williams ; Inciardi et al.
More recent studies have contradicted the view of binge use of crack as the predominant pattern Daniulaityte et al. In this study, baseline data from a sexual risk reduction intervention among heterosexually active, African-American, HIV-positive crack smokers were used to describe binge crack use and to explore differences between binge users and non-binger users, particularly with respect to sexual risk behaviors.
The main study questions were: What does binge use of crack look like in this sample? Are those who report recent binge use of crack i. Specifically, do recent binge users of crack report more frequent sexual risk behaviors compared to those who do not report binge crack use?
To answer these questions, participants' responses about the recency, location, and duration of a typical crack binge were described as well as the amount of crack used, reasons for stopping, and sexual risk behaviors during a typical binge. Recent binge users were then compared to their non-bingeing counterparts in terms of sociodemographic and HIV-related characteristics, lifetime and recent use of crack and other drugs, psychosocial functioning, and sexual risk behaviors.
Understanding how HIV-positive crack users differ across patterns of crack use, particularly how binge crack use relates to sexual risk behaviors, may ultimately inform HIV risk-reduction intervention strategies.
Effective interventions are particularly needed in poorer African-American communities, as these communities experience high rates of crack cocaine use and an increasingly disproportionate burden of HIV prevalence and HIV-related mortality Centers for Disease Control and Prevention Research a , b.
Participants were recruited by posting general notices at health and social service agencies providing services to HIV-positive persons. Interested persons were asked to phone the neighborhood data collection center to be screened for eligibility. If initially eligible and interested, the caller was provided with a full description of the study and asked to come to the data collection center to complete the screening process. The screening process involved completion of a questionnaire and a written consent form and provision of a urine sample to confirm cocaine use in the last 48 h, provision of a dated anti-HIV medication bottles or HIV test results to confirm HIV-positive status.
Quota sampling was used to obtain a sample with equal numbers of males and females. Participants received an incentive of 25 U. Procedures were approved by a university institutional review board. Instrumentation Binge Use Items Questions regarding binge use of crack were developed for the parent intervention study. Possible responses for ending a binge included: SEQ items used for this study include sociodemographic characteristics, HIV history and current medical treatment, lifetime and recent non-injecting and injecting drug use behaviors, and sexual behaviors, including condom use.
These items have shown adequate reliability and have been used in a number of HIV-related research projects Williams et al. Sociodemographic characteristics assessed were age, gender, education, income, marital status, and housing. Participants' use of crack, powder cocaine, heroin, methamphetamine, speedball, marijuana, and alcohol was assessed in a number of ways. Thirty-day recall of recent drug use is reliable and has high validity in other studies using the same or similar measures Weatherby et al.
Sexual behaviors assessed were the number of male and female partners, number of times had vaginal sex, and how often condoms were used for the past 6 months, past 30 days, and past seven days as a validity check. Respondents reporting a history of trading behavior were then asked about when they last traded, the number of trade behaviors, and the number of trade partners in the last 30 days and the last seven days.
Investigators from TCU developed the SRF for use with drug using populations and assessed the instrument's psychometric properties Knight et al. SRF scales have been shown to have good internal reliability and validity Knight et al. Cronbach's alpha scores were calculated for psychosocial measures to check their comparability with those obtained in validation studies.
The SRF measures used for this study included: Means and standard deviations were calculated for continuous variables, and frequencies and proportions were calculated for categorical variables. In order to provide comparisons of clearly distinct groups, analyses excluded those who reported a history of binge crack use but no recent binge crack use, and descriptive statistics were stratified by recent crack binge use vs. Differences between bingers and non-bingers were explored for all variables, conducting t-tests for continuous variables and for normally distributed ordinal variables, Mann—Whitney U tests for ordinal variables with non-normal distributions, and chi-square tests of independence for nominal variables.
In such cases, if there was no significant difference between bingers and non-bingers on the re-categorized variable, the frequencies and proportions for the original categories were reported without a chi-square value to maximize the descriptive information.
Reported P-values for statistical comparisons were based on two-tailed tests, and for t-tests, reported P-values assume unequal variances if Levene's test was significant at the 0. Multivariable logistic regression modeling was used to determine the set of variables that best distinguished bingers from non-bingers while controlling for confounding.
Sexual risk behaviors were viewed as attendant to or co-occurring with binge behavior, rather than explanatory or predictive of binge behavior, and were analyzed separately as described below. Age, years using crack, and psychosocial variables were treated as continuous variables. Amount of income and heaviest use of crack, marijuana, alcohol, and powder cocaine were treated as continuous variables to conserve degrees of freedom.
History of drug treatment and history of powder cocaine, codeine syrup, and injection drug use were dichotomous variables, and no history was the referent category for each of these. Income source, perceived homelessness, and gender were dichotomous variables, and no income source, not homeless, and female gender were the referent categories.
Multivariable analyses were conducted to examine whether apparent differences in sexual risk behaviors between bingers and non-bingers resulted from confounding by other measured factors. By definition, confounding results when the association of one variable e.
So, to rule out confounding here, recent binge vs. Stepwise forward entry methods based on the likelihood ratio were utilized in all models. Analyses of sex trade behaviors were stratified by gender, because gender would have accounted for most of the variance in these behaviors. Ordinal regression was used for ordinal dependent variables, which were number of sex partners in the last 6 months and 30 days.
Logistic regression was used for dichotomous dependent variables, which were never using a condom in the last 30 days, history of each type of sex trade, and trading money for sex, drugs for sex, and sex for drugs in the last 30 days. Condom use was treated as dichotomous, never vs. Recent binge was dichotomous, and no binge history was the referent category.
In ordinal regression analyses, variables measured as continuous were categorized into quartiles to reduce the number of cells i. Other independent variables were treated as previously described. Table 1 shows reported descriptors of a typical crack binge and the last binge.