| Crack
Use and Related Sexual Risk in El Salvador
Research
Method: Basic Research
Principal
Investigator: Julia Dickson-Gomez, Ph.D.
Grant:
Center for Interdisciplinary Research on AIDS, Yale
University, through the National Institutes of Mental Health
(P30 MH 62294)
Partners: Fundación Antidrogas de El Salvador (FUNDASALVA); Universidad Centroamericana José Simeon Cañas
Dates
of Study: 2002-2005
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Background
Over the last decade, both HIV/AIDS rates and crack use have increased dramatically in El Salvador. In the United States, crack use has been associated with a number of sexual behaviors that may contribute to the spread of HIV and AIDS. Many researchers have argued that crack use has contributed to changes in the conditions in which street sex work takes place, including lowering prices for sexual services, higher risk sexual practices, more sex partners and direct sex for crack exchanges. Also contributing to HIV risk is a higher prevalence of physical attack and rape of crack using women. High-risk sexual activities are also prevalent among gang members and sex is used to initiate female gang members. This study was the first to explore the social context in which crack is consumed and HIV risk occurs in El Salvador. This information can be used to design targeted HIV prevention interventions among crack using commercial sex workers and gang members in El Salvador.
ICR has conducted numerous studies about the confluence of drug use, unsafe sex, and HIV risk on the local, national and international arenas. In Study of High-Risk Drug Use Settings for HIV Prevention, researchers observed sites where individuals inject and smoke drugs in Hartford, a similar approach to that used in San Salvador. Project staff then built on these findings to develop HIV Prevention in High-Risk Drug Use Sites: Project RAP, training active drug users to disseminate risk-reduction messages and materials to their peers who use drugs and in the places they use them. Internationally, ICR currently conducts HIV prevention research in India (International Initiatives to Prevent HIV/STD Infection) and China (Microbicide Acceptability for HIV/STD Prevention Among Female Sex Workers in Southern China).
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Project
Details
Through qualitative in-depth interviews with 23 crack smoking women and 15 crack smoking men in urban El Salvador, this study set out to determine whether crack use is associated with high-risk sexual behaviors. This population and a smaller sample of 20 female sex workers were asked about personal history, including childhood and school experiences and family composition; drug use history; drug use sites, including where drugs are bought and consumed, categorizations of sites, rules of usage at the sites, and whether sex is exchanged for drugs or money; subsistence strategies to support drug use; gang involvement; sexual experiences and HIV risky behaviors while smoking crack; violent experiences while smoking crack; initiation into sex work, and whether this preceded or followed initiation into drug use; sexual experiences and use of condoms with clients and regular partners; and violent experiences encountered in sex work. The study intentionally oversampled women, because research conducted in the U.S. indicate that women who exchange sex for money or drugs have significantly more partners and are at higher risk than their male partners. The project also explored the extent to which women participated in or were excluded from illegal income-generating activities other than sex exchanges in order to support their drug use.
Project Findings
Crack smokers and commercial sex workers were recruited through different methods for the study. However, both populations reported high prevalence of crack use and sex for crack or sex for money exchanges, including 30% of crack smoking men who reported engaging in such exchanges. Nearly all participants reported engaging in unprotected sex. Though the interviewers did not ask about HIV status, 8.5% of the 58 total participants volunteered that they were HIV positive; this self-report data indicates that HIV rates in the San Salvador metropolitan area are probably higher than official statistics reveal (0.6% according to USAID's Bureau of Global Health 2003).
Most of the women in the study had been raped before the age of 14, and therefore viewed themselves as "ruined" and unworthy of love. This internalized stigma from childhood sexual abuse influenced their decisions to engage in sex work and to use drugs.
One-third of study participants were former or current gang members. Results from this project also indicate that gang members are vulnerable to drug use and HIV risky sex. While almost all participants reported that their gangs had rules controlling or prohibiting the use of many drugs, particularly crack, these rules were often ineffectively enforced, and many became addicted to crack. Crack addiction, in turn, led many to distance themselves from their gangs. They were then forced to engage in sex exchanges to maintain their drug habits as the income generating activities they engaged in with their gang in their own neighborhoods, such as extortion or robbing, were no longer feasible.
The term "remolque" refers to gang related sexual victimization; this includes forcing a female initiate to have sex with multiple gang members in succession, and the group rape of a female by males in the gang. Condoms are almost never used during remolque. The male perpetrators come in contact with semen from multiple men, and the female victims experience vaginal trauma. For both groups, this increases the risk of HIV infection.
The results from this pilot study will be used to build a conceptual framework and organizational infrastructure for subsequent NIH-funded studies, exploring the social context of drug use and HIV risk in El Salvador. Such research could eventually provide the foundation for a peer-led HIV prevention intervention for Salvadoran risk groups - including crack smokers, commercial sex workers, and gang members.
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