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Abstract
Objectives Young age coupled with a high HIV prevalence among injection drug users (IDUs) and the prevalence of drug use in Eastern Europe can lead from an HIV epidemic concentrated among IDU to a self-sustained heterosexual HIV epidemic. Our objective was to explore the contexts of the prevention of sexual transmission of HIV among IDUs and their sexual partners and to provide insight into beliefs and behaviours related to condom use.
Methods The authors undertook in-depth qualitative interviews to explore narratives about experience of preventing sexual transmission of HIV among 27 individuals (15 current IDUs and 12 main sexual partners of IDUs) in Kohtla-Järve, Estonia.
Results The safe-sex ‘norm’ was not common and factors that tended to reduce condom use included valuing the relationship above health risks, established gender roles, perceptions that condoms distributed via harm reduction programmes were of low quality and the stigma attached to HIV status disclosure. HIV risk management strategies among participants included consistent condom use and serosorting but were countered by a fatalism that encompassed consciously subjecting oneself to the inevitability of HIV infection in an HIV-discordant sexual partnership.
Conclusions Qualitative methods can significantly contribute to the prevention of sexual transmission of HIV among and beyond IDUs by improving our understanding of risky behaviours and the reasons for such behaviours that can be incorporated into tailored public health interventions.
- Epidemiology
- STD
- STD clinic
- HSV-1
- vulval skin disease
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Introduction
Injection drug use accounts for over 60% of all HIV infections in the WHO East European region.1 Transmission of HIV from injection drug users (IDUs) to non-injecting sexual partners may serve as a bridge for the expansion of the epidemic into the heterosexual non-drug-using population.2–4 It has been suggested that in Eastern Europe and Russia, the spread of HIV from IDUs into the general population may lead to significant epidemics (unlike in Western Europe and North America), given the size and composition of vulnerable populations in these regions.5
Estonia is confronted with an HIV epidemic driven by injection drug use that has led to the highest prevalence of HIV infection among adults aged 15–49 years in Europe (1.2% (1%–1.5%) in 2009).6 The estimated prevalence of injection drug use is 2.4% among 15–44-year-olds in Estonia,7 and the HIV prevalence among IDUs is high (40%–90%).8–10 Among IDUs surveyed in Tallinn in 2007, two thirds (67%) reported having a main partner, half (52%) reported having one or more casual partners and close to half (44%) reported having two or more sexual partners within the last 12 months. Condom use varied by partner type: always using condoms was reported in one third of main partnerships (33%) and by nearly two thirds (60%) of IDUs reporting casual partners.11
Harm reduction programmes targeted to IDUs have primarily focused on reducing drug-related risk behaviour but have paid little attention to sexual risk behaviour beyond the provision of condoms.12 13 Except for a few reports from Russia on risk behaviour and HIV occurrence among IDUs and their non-drug-using sexual partners,14 15 little attention has been paid to bridging populations of IDUs which may contribute to an expanding heterosexual HIV epidemic in Eastern Europe. Several quantitative studies from Eastern Europe have found that IDUs are sexually active, have both injecting and non-injecting partners and use condoms irregularly.8 14–16 The ongoing challenge of finding more effective HIV prevention strategies requires focused and contextualised knowledge. Qualitative research methods are valuable tools for achieving this.17 18
In this report, we present findings from a qualitative study exploring the contexts of the prevention of sexual transmission of HIV, focusing on main heterosexual relationships, in which condom use is especially low, to provide insight into beliefs and behaviours related to condom use among IDUs and their sexual partners in Kohtla-Järve, Estonia.
Methods
Study design
In-depth interviews with current IDUs and IDUs' main heterosexual partners were undertaken in Kohtla-Järve, in the northeastern region of Estonia where the HIV epidemic has been particularly severe. This non-probability purposive sample set minimum quotas on HIV status (infected/non-infected), age (20 years and older), gender and drug injection status (non-injecting heterosexual partners of IDUs). We selected the purposive sampling dimensions to ensure variation in relation to contextual factors theorised to determine differences in sexual risk taking.19 Participants were recruited through collaborating harm reduction services, were eligible for the study if they spoke Estonian or Russian, were aged 18 years or older, had used injection drugs in the past 2 months (IDUs) or did not inject drugs themselves but were in a current relationship with an IDU (sexual partners). To ensure that respondents met the inclusion criteria for IDU/non-IDU, participants' skin was checked for the presence or absence of injection marks. No pairs of partners were included.
An interview guide contained key questions about types of partnership, use of condoms, risk perception and risk reduction strategies. Interviews were conducted by the authors (KA-O and AM), who were experienced in qualitative interviewing techniques. All interviews were conducted in the participants' native language and in private, were tape-recorded after informed consent, lasted about 60–90 min and were transcribed verbatim for analysis. Participants were compensated with a $10 gift coupon for their time and contribution.
Data analysis
Coding of data was descriptive and thematic.19 All interviews were coded initially for emerging core descriptive content with coding further refined in an iterative process of data coding, charting and interpretation. Key emergent thematic categories relevant to this analysis included sexual partnerships, condom use, efficacy of condom use, HIV and risk reduction. Data were processed by hand. Each study subject's transcript was summarised in a separate file on the computer. In order to protect participants' anonymity, interviewees are identified only by gender, IDU, sex partner and HIV status.
Participants were interviewed in two waves that enabled provisional coding to inform ongoing recruitment and purposive sampling as well as refinement of topic areas for subsequent interviews. At the interim analysis, factors related to non-condom use emerged as a key theme and were thus given greater emphasis in later interviews.
The Ethics Review Board at the University of Tartu approved the study.
Results
In-depth interviews were conducted from February to March in 2008 and from March to April in 2009.
Participants
The sample consisted of 27 individuals: 15 current IDUs (11 men and 4 women) and 12 main sexual partners of IDUs (all women) (table 1).
Participant characteristics: current IDUs and main sexual partners of IDUs interviewed in Kohtla-Järve, Estonia
Twelve IDUs (eight men and four women) reported having a current main sexual partner, and all 12 women interviewed as sexual partners of IDUs reported having a current main male partner who injected drugs or was receiving methadone treatment for opiate dependence.
Of the 24 study subjects in a regular/main sexual relationship, 14 reported that their main sexual partner had concordant HIV status (eight HIV positive and six HIV negative partnerships). Four HIV-infected IDUs had an uninfected main partner and two had partners with unknown HIV status. Among the uninfected, two IDUs and four sexual partners had HIV-uninfected main partners and three interviewees (one IDU and two partners) had main sexual partners with unknown HIV status.
Most of the respondents, both IDUs and sexual partners of IDUs, assessed their relationship to be close and trusting in which emotions and sexual feelings were equally shared. Two of the IDU sexual partners reported not fully trusting their partners. One woman said “I prefer not to trust than to trust because he is a drug addict and that makes it difficult” (sex partner, HIV positive).
Condom use
Personal experiences
IDUs
Experience with condom use varied from never used (female IDU), using once in a lifetime to reporting using condoms always or almost always (four IDUs—two men and two women).
The main reasons that the male IDUs reported for condom use were to prevent pregnancy and HIV transmission. One IDU recently stopped condom use after his partner got pregnant. HIV transmission as a concern was especially emphasised by IDUs who had been in prison (related to the fear of prosecution due to knowingly exposing a sexual partner to HIV).
Sexual partners of IDUs
Similarly, some partners reported that they never used a condom. Two women reported using condoms regularly with their partners to prevent pregnancy. Some of the sexual partners had used condoms at the start of relationships, or at previous times, but did not use condoms currently.
Reasons for not using condoms
Participants underlined the emotional barriers and reduction in physical pleasure associated with condom use. There was widespread belief that using a condom diminishes the feeling or sensation of sex box 1.
Reasons for not using condoms among current IDUs and main sexual partners of IDUs interviewed in Kohtla-Järve, Estonia
Extract 1: Belief that using a condom diminishes the feeling or sensation of sex“Not a secret, really. The feeling is not the same with a condom. It is better, more pleasant without a condom” (IDU, male, HIV negative)
“Actually I do not like it. That is why I have practically never used them during our life together. We did try when we got married but it did not suit me and we have never tried again… So we just stopped using them” (sexual partner, HIV negative)
“Well, men say that having sex with a condom is the same as smelling roses wearing a gas mask. Girls buy that. At first they insist but then they just give in” (sexual partner, HIV positive)
Extract 2: General population/community norm of not using condoms“HIV has no influence on condom use. They just do not care. Maybe 10% of acquaintances (HIV infected) use it” (IDU, male, HIV positive)
Extract 3: Already being HIV-infected“What could be the result of not using a condom? …Well, pregnancies and sexually transmitted infections. But this does not worry me at all” (sexual partner, HIV positive)
Extract 4: Main partnership—unprotected sex is viewed as a sign of trust and closeness in the relationship which condom use would undermine“If I would demand condom use … He would probably think I am seeing someone else. I believe that would be the only thought he might have in connection with this” (IDU, female, HIV negative)
Extract 5: Not having condoms at hand, unavailability of condoms“It's obvious, I do not use it when I have none to use… this has happened a couple of times. Lack of a condom won't stop me from having sex, a condom is not that important” (IDU, male, HIV positive)
Although providing condoms was considered to be the man's responsibility, the demand/request to use a condom was expected to come from the woman. Still, the prevailing feeling was that men could refuse to use a condom. Women interviewed mentioned “Probably I could not refuse. I would simply take some purely personal precautions” (sex partner, HIV negative) or “If a partner refused to have sex with a condom I would do it without a condom anyway” (IDU, female, HIV positive).
Already being HIV positive was also given as a reason for not using condoms, in which case preventing other sexually transmitted infections (STIs) and unwanted pregnancies ranked as low priorities. But there were also exceptions. One HIV-infected male IDU revealed “Because I am afraid, I have been ill from 2000, I mean infected, and I am afraid of infecting someone else. That is why I certainly use condoms.” Acknowledging HIV status can also be hindered by the community norm of not using condoms.
Unprotected sex is viewed as a sign of trust and closeness in a relationship which condom use would undermine. Although condom use was acceptable for some partners at the beginning of a relationship, for a sizeable proportion of respondents it would be an insult to request condom use because this would question their own or their partner's fidelity. An extreme example of the value placed on a steady and trusting relationship was given “Yes, I know of a guy who was positive and then met a girl and she fell in love with him and became infected because she wanted to. Then they broke up, how about that. I do not understand why anyone would do such a thing” (IDU, male, HIV positive). Conversely, a fatalistic misconception of inevitable infection of an uninfected partner in a discordant partnership was expressed more than once. And once both partners are infected, there is no reason to use precautionary measures anymore. “If both are HIV positive, why would they need a condom?” (IDU, male, HIV negative).
Nevertheless, some participants in stable relationships were confident that it would be easy to ask and explain their reasons for wanting to use a condom and that they would not be rejected. But disclosing one's HIV status is not always easy. In one case, an HIV-positive IDU had not told his girlfriend (with whom he had been having a relationship for 6 months) about his HIV status and was afraid of letting her know and he confessed “I say that we should use a condom to prevent pregnancy … I am afraid to tell her my HIV status…. Maybe I will, soon…. If I would keep insisting on using condoms all the time, she would get suspicious and that is why we sometimes do it without a condom.” Although there was clear concern among IDUs about their main partner's well-being, there was less concern for casual partners. One male IDU (HIV positive) stated “I do not care. Of course, I am worried only about my girlfriend.”
Other reasons for not using condoms mentioned by participants included not caring about one's health, or that of others, being under the influence of alcohol and unavailability of condoms.
Efficacy of using condoms
In general, most respondents considered condoms to be effective for preventing STIs including HIV but not so reliable for preventing unwanted pregnancies. Three participants considered condoms to be ineffective or unreliable. A male IDU (HIV negative) said “I think you can catch an STI with a condom as easily as you can without it. With HIV I think the chances are fifty-fifty.” Almost half the respondents claimed that slippage and/or breakage had happened while using a condom. Breakage was reported more often. One sex partner associated condom breakage with acquiring HIV from her partner “A condom broke once and my partner infected me.” Incorrect condom use was also described, and several participants who reported using condoms were referring to the practice of putting a condom on just before ejaculation box 2.
Beliefs on efficacy of condoms and accurate condom use current IDUs and main sexual partners of IDUs interviewed in Kohtla-Järve, Estonia
Extract 1: Most respondents considered condoms to be effective for preventing sexually transmitted infections but not so reliable for prevention of unwanted pregnancies“I don't know why people use condoms? Condom does not protect from pregnancy … Not always, sometimes girls become pregnant even with a condom. Also not always, for diseases, condoms can break …” (IDU, male, HIV positive)
Extract 2: Frequent slippage and/or breakage of condoms“Condom breakage … this has happened several times. They become dry quickly and you might not feel that, but then you will feel that one part of your penis is protected and another part is not” (IDU, male, HIV negative)
Extract 3: A belief that efficacy of condoms depends on their quality“It depends on the condom. I have already mentioned that the ones distributed for free break easily. The ones sold at the store are expensive but more durable. The efficiency level is probably not quite 100% … Condoms sold at pharmacies provide 80% protection, the ones issued here (at the centre)—about 60%. No condom can offer 100% protection … It is fine as long as the condom is intact. The tiniest hole compromises the whole thing” (IDU, male, HIV negative)
Extract 4: A belief that condoms distributed free in HIV prevention and harm reduction centres are of low quality“Condoms distributed at centres become dry quickly and you need three condoms to finish having sex. When I learned that condoms are offered here [at the centre], I did use them. But as I tried them I discovered that they become dry and break, that is why I now buy condoms at a store. Their quality is better” (IDU, male, HIV negative)
The quality of condoms emerged as an important issue. Almost all the respondents said that the efficacy of condoms depended on their quality. There was a general belief that condoms distributed free in HIV prevention and harm reduction centres are of low quality and prone to break. This experience has damaged the image of condoms among the respondents. However, only three of the respondents reported that, due to the low quality of the free condoms provided by the centres, their primary source of condoms was stores or pharmacies.
Risk reduction strategies
Among those not infected with HIV, condom use was more common and considered to be important. Those already infected with HIV tended to believe that their friends rarely or never use condoms, but when they did, it was to avoid infection box 3.
Risk reduction strategies among current IDUs and main sexual partners of IDUs intervjewed in Kohtla-Järve, Estonia
Extract 1: Condom use“Well, my friends treat this matter seriously. They understand that if one of the two becomes infected then the other will become infected as well and if one does not warn the other, it is a serious mistake. Nobody needs this kind of grief, they all agree on that” (IDU, male, HIV negative)
Extract 2: Serosorting“After diagnosis I have had less sex, partners are apprehensive—those who have HIV agree to have sex, others are too afraid…. I ask about the serostatus of my partners” (IDU, male, HIV positive)
“If someone learns that a girl is HIV-positive, no one will sleep with her. Maybe just spend time with her, but no sex” (IDU, male, HIV negative)
Serosorting was reported as a frequently used risk reduction strategy. The general norm is that people living with HIV/AIDS have to pick sex partners among themselves, and usually non-infected IDUs do not have sexual relationships with HIV-positive individuals. Correspondingly, some respondents who were not infected mentioned that they always try to learn a person's serostatus before they have sex.
Discussion
Unprotected sexual intercourse within partnerships consisting of IDUs and non-IDUs coupled with the high HIV prevalence among IDUs and IDU population prevalence close to 2% of the adult population7 20–22 suggests that the ‘first wave’ in the bridge population itself can lead to a self-sustained heterosexual HIV epidemic.5
Ethnographic and qualitative studies on sexual behaviour have made significant contributions to the understanding of STI/HIV transmission dynamics. Our aims were to explore the concept of the prevention of sexual transmission of HIV in the community of IDUs and their main sexual partners and to reveal behaviours or cultural factors that could be relevant for developing prevention strategies.
This study has several limitations that are characteristic of all exploratory qualitative studies into attitudes and beliefs. These include small sample size, non-random selection of respondents and socially desirable response bias. Another limitation is that we did not interview non-injecting male partners of female IDUs. Despite these limitations, several issues emerged from the in-depth interviews, which may help guide the design of prevention and intervention programmes.
The primary issue concerns low and inconsistent condom use. The safe-sex ‘norm’ is not common in this population. Factors acting to reduce condom use include valuing relationships above health risks, established gender roles, condom quality at harm reduction programmes and the high degree of stigma attached to HIV infection within this group of people.
HIV risk management strategies among participants included consistent condom use and serosorting. Even to the extent where an IDU and/or HIV HIV-positive person is willing to use a condom, the community norm of not using a condom may be adopted in order to avoid revealing or raising questions about their IDU/HIV status—as one participant stated: “If I would keep insisting on using condoms all the time, she would get suspicious and that is why we sometimes do it without a condom.”
Different reasons emerged for not using condoms in different types of sexual partnerships. In main partnerships, the strength of the relationship (ie, level of trust and commitment) is prioritised above the potential risk from one partner's high-risk behaviour. In this context, a request for condom use might elicit the fear of accusations of infidelity.
In serodiscordant couples, a fatalistic acceptance of eventual infection of an uninfected partner leads to underemphasising condom use to the same extent that it occurs in HIV status concordant partnerships. Among couples who are both HIV positive no point is seen in using condoms since other STIs and unwanted pregnancies are considered to be threats of low importance. It is important to note that the wish to conceive emerged as a relevant topic, which is not surprising given the young age of IDUs (and their partners) in Eastern Europe.8 10 14 For casual relationships, our findings are even more worrisome: drug users do not seem to feel responsible for preventing sexual transmission of HIV to this class of partner. The occurrence of serosorting among IDUs has been reported before.23 While serosorting was mentioned as a strategy for risk reduction, this seems an unreliable strategy given the low knowledge of true HIV status among IDUs.9 24
We found negative attitudes towards condom use that have been described before25 such as—“sex with a condom is the same as smelling roses wearing a gas mask.” Further sexual risk reduction among IDUs might be achieved if effective methods can be developed for providing competing rationales that combat men's beliefs that condom use will decrease their enjoyment of sex. It appears that drug users lack the practical, communication and self-management skills needed to use condoms correctly and consistently when the gender roles generate barriers to open communication.25
The perception of the low quality of free condoms distributed by harm reduction programmes implies that the distributed condoms may not meet the needs of the high-risk community. Addressing this issue should be a priority. If condoms distributed by harm reduction programmes are actually of high (or equivalent) quality to those obtained commercially, then investigation of the reasons for the perception of low quality is needed. Several explanations are possible, but the most plausible one is that participants may not be sufficiently educated about correct condom usage and may thus experience problems with use but attribute these problems to the condoms. Providing education on correct usage is probably needed. Additional social marketing approaches such as providing multiple brands of condoms or condom promotion advertisements for the brands selected by the harm reduction programmes may be an effective way to dispel negative attitudes about condom quality.26
Given the importance of sexual contact in the spread of HIV among both men and women, it is imperative to understand the variability of behaviours and reasoning behind the behaviours that put people at risk. Our work suggests several strategies for tailoring interventions targeting the prevention of sexual transmission of HIV among IDUs and their partners in Estonia and perhaps in other areas in the region.
First, providing multilevel interventions (social, couple, individual) focusing on harm reduction and on reproductive health and family planning issues is of critical importance. Our findings underscore the need to tailor prevention messages to the type of sexual relationships (steady or casual) and to include partner-specific practical, communication and self-management skills building. Last but not least, combating men's beliefs about decreased pleasure with condom use and potentially addressing correct condom use are needed.
Key messages
Behaviours and reasoning behind risk behaviours for sexual transmission of HIV among IDUs vary.
Tailored public health interventions should take account of, and understand, the variability in risk behaviours.
Acknowledging reproductive health needs and partnership characteristics is critical for effective interventions intending to modify sexual behaviour among IDUs.
References
Footnotes
Funding This study was supported by the grant # ESX0-2722-TA-06 from CRDF (USA); Norwegian Financial Mechanism/EEA (grant EE0016); New York State International Training and Research Program (grant 2D43TW000233), NIH—Fogarty International Center and National Institute on Drug Abuse; the Basic Financing and the Target Financing of Estonian Ministry of Education and Research (grant SF0180060s09).
Correction notice This article has been corrected since it was published Online First. The sentence ‘an HIV epidemic concentrated among IUD’ has been amended to ‘an HIV epidemic concentrated among IDU’.
Competing interests None.
Ethics approval The Ethics Review Board at the University of Tartu (Estonia).
Provenance and peer review Not commissioned; externally peer reviewed.