My place, your place, and no place: Behavior settings as a risk factor for HIV-related injection...

American Journal of Community Psychology, VoL 22, No. 3, 1994

My Place, Your Place, and No Place: Behavior Settings as a Risk Factor for HIV-Related Injection Practices of Drug Users in Baltimore, Maryland I

Carl Latkin, 2 Wallace Mandell, David Vlahov, Maria Oziemkowska, Amy Knowlton, and David Celentano Johns Hopkins University

Information is sparse on the social context of illicit drug injection behaviors and their relationship to HIV infection. This study examined relationships between injection settings, injecting with others, and HIV risk behaviors of sharing needles and not cleaning contaminated needles in a sample of 630 inner-city injecting drug users in Baltimore, MD. Through open-ended interviews, five primary settings of injection behavior were identified. These settings included one's own, friends' and mother's residence, shooting galleries, and semipublic areas. Most participants reported injecting in their own residence (92%) and friends' residence (86%) in the prior 6 months. In a multiple regression analysis, injecting at friends' residence, in shooting galleries, and in semipublic areas and frequency of injecting with others were significantly associated with frequency of sharing uncleaned needles, "slipping" (i.e., failure to disinfect shared needles), and not always cleaning used needles before injecting. Results suggest that interventions may benefit from targeting settings as well as behavic, rs to reduce the spread of HII~.

KEY WORDS: HIV infection; injection drug users; injection practices; behavior settings; needle sharing; substance abuse; risk factors.

1This research was supported by grants DA04334, DA05911, DA06313, and DA08985 from the National Institute on Drug Abuse.

2All correspondence should be addressed to Carl Latkin, Department of Mental Hygiene, The Johns Hopkins University, School of Hygiene and Public Health, 624 N. Broadway, Baltimore, Maryland 21205.

415

0091-0562/94/0600-0415507.00/0 �9 1994 Plenum Publishing Corporation

416 Latkin r aL

The study of the relationship between natural settings and social behavior has a long history in psychology. The most prominent work on social settings is that of Barker and colleagues (Barker, 1978; Barker & Schoggen, 1973; Barker & Wright, 1955; Schoggen, 1989). The present study examined the utility of studying settings of injection drug use for understanding behaviors associated with the risk of HIV infection.

Injection drug users continue to be at high risk for HIV infection, primarily through the practice of sharing contaminated needles (Marmor et al., 1987). Previous studies have examined relationships between needle sharing and motives to share; knowledge, beliefs, attitudes about drug use and HIV; demographic characteristics including economic status; patterns of drug use; and legal constraints (Magura et al., 1989; Mandell, Latkin, Oziemkowska, Vlahov, & Celentano, 1994b). Despite high levels of knowledge about the risk of HIV infection through sharing needles, many drug users report con- tinued needle sharing and inconsistent cleaning of needles with bleach (Celentano, Vlahov, Cohn, & Anthony, 1991). Experimental interventions targeting individual injection drug users have had limited impact on changing the behavior of needle sharing. Many interventions developed for HIV prevention among injection drug users lack adequate control groups and random assignment. Those studies that report risk reduction often find that the control groups change as much as the experimental group (Fisher & Fisher, 1992; Magura et al., 1991; Mandell, Latkin, Oziemkowska, Vlahov, & Celentano, 1994a). Thus additional information on the dynamics of needle sharing may be useful in designing more effective interventions.

Another dimension of needle sharing, one that has received little attention to date, is the interplay between injection behaviors and the setting in which they occur. In the study of HIV among injection drug users, attendance at one type of setting, shooting galleries, has consistently been found to be a risk factor for HIV infection (Schoenbaum et al., 1989; Vlahov et al., 1990). Shooting galleries are locations where injection equipment is typically available for rent. Injection drug users often report attending shooting galleries to avoid arrest and harassment for carrying injection equipment. De- tailed ethnographic studies of shooting galleries have been conducted by Page and Weibel and their colleagues and local taxonomies of shooting galleries have been formulated (Ouellet, Jimenez, Johnson, & Weibel, 1991; Page, 1990; Page, Smith, & Kane, 1991). Although Page et al. (1991) did not ob- serve needle sharing in shooting galleries, they noticed that used needles were often rinsed only with water before they were returned to a common con- tainer. As part of this study, Chitwood et al. (1990) collected needles from the common containers at several shooting galleries they observed and found that of the needles analyzed 10% tested positive for HIV antibody.

Risk Factors for HIV-Related Injection Practices 417

Based on their ethnographic work, Ouellet et al. (1991) categorized shooting gaUeries in Chicago into three groups based on observed roles and role relations: cash galleries, taste galleries, and free galleries. Cash galleries were described as businesses with regular hours, an admission fee, and fees for injection equipment rental and other injection services. Taste galleries were defined as places where friends allow other friends or acquaintances to inject drugs. Sharing a small amount of drugs is reported to be a form of payment for use of the taste gallery. Free galleries were defined as "any space where injection drug users regularly gather to inject drugs, but where there is no admission fee (either money or drugs)." The authors reported that the injection drug users they interviewed did not always agree on what constituted a shooting gallery. Moreover, in comparing their findings to studies of shooting galleries in New York and San Francisco, they concluded that the role and role relations of shooting galleries differ by geographic location.

Although shooting galleries have been identified as high-risk settings for HIV transmission, other settings in which drug users inject and the relationship of these settings to HIV risk behaviors have received little attention in the literature. The present study examined relationships among injection settings, frequency of injecting with others, and high-risk injection behaviors. We hypothesized that due to variations in the role and role relations among settings some settings would be associated with higher rates of HIV-related injection behaviors. Specifically, we hypothesized that individuals would be more likely to engage in unhygienic injection practices in settings in which they have little personal control relative to others present (e.g., shooting galleries, and abandoned buildings and other semipublic areas) and settings in which they have lower status (e.g., friends' residences). We anticipate that shooting galleries attract individuals who are less concerned about injection hygiene. We also hypothesized that due to a lack of defined roles associated with HIV risk reduction it is unlikely that bleach and clean tools would be available in abandoned buildings and other semipublic areas.

Individuals were hypothesized to be more likely to engage in hygienic injection practices in settings in which they have the most control over injection practices and the highest social status (e.g., when at their own residence they may inject first and let others follow).

The present study used a combination of a grounded theory approach (Glaser & Strauss, 1967) and an epidemiological perspective on infection transmission. Using a grounded theory-oriented approach, we examined how individuals categorize the settings in which they inject drugs. We then assessed statistical associations between these injection settings and HIV- related behaviors. Finally, we examined whether presence in specific injection settings was associated with HIV-related behaviors independent of the presence of other drug users when engaging in HIV-related behaviors.

418 Latkin et aL

METHODS

Participants

Participants were in the Stop AIDS For Everyone (SAFE) study, a psychoeducational intervention to reduce HIV-related injection behaviors. SAFE participants were a nontreatment sample initially recruited from the AIDS Links to Intravenous Experiences (ALIVE) study, a prospective study of the natural history of HIV infection in injection drug users in Baltimore, MD. The means of recruitment for the ALIVE study were community outreach and word-of-mouth, with 86% of the participants first learning about the study by word-of-mouth (Vlahov et al., 1991). Enrolled in the ALIVE study are 2,291 current or former injection drug users. The follow-up rate for ALIVE participants has exceeded 85%. At the ALIVE study's baseline, 90% reported injecting drugs within the prior year, 61% reported sharing needles, and 24% were found to be HIV seropositive (Vlahov et al., 1990). Participants of ALIVE are interviewed every 6 months about their risk behaviors, and those who are seronegative receive an HIV antibody test.

At the ALIVE clinic participants who at their regular 6-month follow-up visit reported injecting and sharing drugs in the preceding 6 months were informed that they were eligible to participate in the SAFE study. The SAFE clinic was located three blocks from the ALIVE clinic. Participants were randomly assigned to either a control or experimental condition. Those in the experimental condition were asked to bring into the clinic individuals with whom they had shared drugs in the prior 6 months. These individuals were also interviewed. All eligible participants were administered a face-to-face interview on their sociodemographic background, HIV-related behaviors, and names of persons in their personal networks. The data for the present study were collected in 1991 and 1992.

Of the total 642 SAFE participants, 293 were recrui ted from among the 411 ALIVE study participants informed at an ALIVE visit of their eligibility for the SAFE study. The remaining 459 SAFE participants were individuals with whom the 293 ALIVE part icipants reported sharing drugs in the prior 6 months, 24 of whom were them- selves ALIVE participants. In total, 46% of the sample were ALIVE participants. Of the 642 participants, 630 repor ted injecting drugs within the prior 6 months.

Of the current drug injectors the majority of the participants were African American males who had less than a 12th-grade education, and reported receiving public assistance in the prior 10 years (Table I). The

Risk Factors for HIV-Related Injection Practices

Table I. Demographic Characteristics, Life Events, and Drug Use Patterns of 630 Injection Drug Users Enrolled in the SAFE Study, Baltimore, MD, 1990-1991 a

Sample Characteristics %

Gender: Male

Race: African-American

Education: < 12th grade

Married

Cohabitating: Living together as if married

Employed currently

Homeless within last 10 years

Public assistance within last 10 years

Arrested within last 10 years

Bed patient in a hospital within last 6 months

Incarcerated within last 6 months

Injected cocaine within last 6 months

Injected cocaine daily in last 6 months

Injected heroin within last 6 months

Injected heroin daily in last 6 months

Used crack within the last 6 months

79.7

97.5

54.1

4.6

22.7

11.8

50.3

83.6

76.8

24.7

18.7

94.0

48.1

88.9

51.6

26.3

Mean and median year of birth 1953

a Missing data on 3 participants.

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mean and median age for men was 39 years, with a range of 24-56; for women the mean age was 37 years, and the median 35, with a range of 27-55. Twenty-s~ven percent of the participants recruited from ALIVE were HIV seropositive. HIV status was not available on the participants who were not in the ALIVE study. The demographic characteristics of the SAFE sample are highly similar to the ALIVE sample, except there was a greater proportion of African Americans (98 vs. 89%) and higher level of unemployment (88 vs. 77%) in the SAFE sample as compared with the ALIVE sample.

420 Latkin el al.

Instruments

Data on injection settings were collected in two stages. First, in the formative research stage interviews were conducted using open-ended questions and probes for eliciting information on injection locations. In the pilot surveys participants were asked to name all of the types of places where they injected drugs in the prior 6 months. Five categories of settings emerged from the coding, and so five corresponding closed-ended questions were formulated for the survey interviews. The survey questions asked whether the participant had injected drugs in each of the following setting categories within the last 6 months: (1) "At your own place"; (2) "At a friend's place"; (3) "In a shooting gallery, that is, a place where people go to rent, borrow or buy a needle"; (4) "At your mother's place"; (5) "On the street, in a park, in a car, on rooftops, public bathrooms, or an abandoned building." The participants were also asked if there were other places not mentioned where they had injected in the previous 6 months. The participants were then asked the setting in which they injected most often in the prior 6 months.

Unhygienic practices were assessed with three questions. Participants were asked, "During the last 6 months, how often did you share a needle? (By sharing a needle we mean using a needle right after somebody else had used it without cleaning it with bleach or alcohol)." The second item asked, "Do you always clean used needles before injecting?", and the third question was, "When was the last time you had a 'slip', that is, you used a needle right after somebody else had used it without cleaning it with bleach or alcohol?" To assess the degree to which injecting drugs was a social activity, participants were asked "During the last six months how often did you shoot drugs: "alone" and "with others (in each others' company)?" An additional probe for this question defined the term "injected drugs with others" as "injecting while other drug users were in the same room."

Analyses

Chi-square analyses were used to assess the relationship between the independent variables of injection settings, frequency of injecting with others, and the dependent variables of always cleaning used needles, frequency of sharing, and "most recent slip" (sharing needles without disinfecting them). Thereafter, hierarchical multiple linear regression models and logistic regression models were employed to examine the predictive power of the variables of injection settings and frequency of injecting with others.

Risk Factors for HIV.Related Injection Practices 421

RESULTS

Drug Use and Needle Cleaning Practices

Cocaine and heroin by injection were the drugs of choice in this sample: 94% of participants reported injecting cocaine and 89% reported injecting heroin within the last 6 months; 62% of the respondents reported daily use of cocaine or heroin. A majority of participants reported engaging in HIV-related injection practices: 46% shared needles more than once a month, and only 47% reported they "always cleaned used needles before injecting." About half (47%) reported "slipping" (i.e., not cleaning before injection) within the last month (Table II).

Injection Settings

Most of the participants reported that they injected at their own place (92%) and at friends' places (86%) in the prior 6 months. Of the settings participants reported injecting most frequently, over two thirds (68%) reported injecting most often in their own place, while fewer reported injecting most often at a friend's place (24%), in a shooting gallery (4%), at their mother's (2%), or in a semipublic area (3%). Most (68%) of the participants reported injecting in three or more of the five locations. Seventeen participants mentioned other injection sites; shelters, hospitals, fast-food restaurants, relatives' homes, and jail were each mentioned by more than one participant. Of these other settings the most frequent mention was hospitals, which was listed by 5 participants. Most of the participants (75%) reported that they injected with others half the time or more, and 14% reported always injecting with others (Table 11).

Setting and Injection Practices

In the next analysis we examined the relationship between self-reports of the injection settings and frequency of sharing, always cleaning used injection equipment, and recency of slipping. A Mantel-Haenszel (M-H) chi-square analysis was used to examhle the linear association between the five injection settings and the HIV risk beha~ors of frequency of sharing and slipping. Frequency of injecting with others was significantly associated with these three risk behaviors. Frequency of sharing needles in the prior 6 months was significantly associated with reports of injecting at friends' residences, shooting galleries, and semipublic areas. More recent slipping was also significantly associated with reported injecting at friends' residences, shooting galleries, and semipublic areas. As seen in Table [lI, not cleaning used injection equipment was significantly associated with reports of injecting at friends', shooting galleries, and semipublic areas.

422 Latkln eta/.

Table I1. Frequency of Sharing, Slipping, Injecting with Others and Injection Settings of 630 Injection Drug Users Enrolled in the SAFE Study, Baltimore, MD, 1991-1992

Behavior %

Frequency Sharing needles in the last 6 months a Not at all 32.6 Less than 1 a month 21.2 2-3 times a month 23.8 1-6 times a week 10.7 1 a day or more 11.7

Last time had a slip

Never 34.3 Over 1 month ago 18.4 Within last month 10.9 Last week 17.1 This week 5.3 Yesterday 12.0 Today 2.1

Drug Injection Settings % Yes % Most often

1. At your own place 91.7 67.5

2. At a friend's place 85.8 23.5

3. In a shooting gallery, that is, a place where 28.8 4.1 people go to rent, borrow or buy a needle

4. Mother's place 25.8 1.7

5. Semipublic areas: On the street, in a park, in a car, on 37.7 2.7 rooftops, public bathrooms, or an abandoned building

No. of reported injection settings %

One 13.4 Twp 31.6 Three 30.7 Four 19.8 Five 4.5

Frequency of injecting with others %

Never 0.8 Less than half 24.6 Half the time 27.8 More than half 32.5 All the time 14.3

a Missing data on 5 participants. b Used a needle right after somebody else had used it without cleaning it with bleach or alcohol.


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o ~

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~.~ �9 ~- ~

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424 La tk ln et al.

Frequency of injecting with others was significantly positively associated with a higher frequency of sharing (M-H Z 2 = 14.27, p < .01) and more recent slipping (M-H Z 2 = 12.43, p < .01), and negatively associated with always cleaning used needles (M-H Z2 = 12.03, p < .01).

Multivariate Analyses

Hierarchical linear multiple regression was used to determine if the addition of injection with others and injection settings improved the strength of association between demographic and life history variables and risk injection practices. In the first hierarchical regression model the dependent variable was frequency of sharing unhygienic needles in the prior 6 months (Table IV). In the first step, age, gender, education, pat tern of drug use, and arrest, homelessness, and public assistance benefits in the prior 10 years were included in the model. This step was significantly different from zero (R 2 = .25), F(7, 612) = 5.93, p < .01. In the second step, frequency of injecting with others was added and r e s u l t e d in a s i g n i f i c a n t i m p r o v e m e n t o f R 2 (R 2 = . 3 1 ) , F ( 8 , 611) --- 8.22, p < .01. In the third and final step, the five injection setting variables were added to the model. The addition of these variables also significantly improved the model (R 2 = .39), F(13, 609) = 8.62, p < .01. As seen in Table IV two of the five injection settings, friends' residence and shooting gallery, were significantly associated with frequency of sharing unhygienic needles. These are both social settings in which most individuals present may have little authority to insist on hygienic injection practices.

In a second hierarchical linear multiple regression model recency of slipping was the dependent variable (Table V). Again, the first step included the independent variables of age, gender, education, pattern of drug use, and arrest, homelessness, and public assistance benefits in the prior 10 years. This step produced an association significantly different from zero (R 2 = .23), F(7, 612) = 4.91, p < .01. Likewise, in the second step, frequency of injecting with others was added and resulted in a significantly improvement of R 2 (R 2 = .27), F(8, 611) = 6.19, p < .01. In the third and final step, the five injection setting variables were added to the model. The addition of these variables also significantly improved the model (R 2 -- .35), F(13, 609) = 6.72, p < .01. In this model three of the five injection settings, friends' residence, shooting gallery, and semipublic areas, were significantly associated with recency of using unhygienic needles.


Table IV. Multiple OSL Regression Analysis of Frequency of Sharing Injection Equipment in the Prior Six Months for 630 Injection Drug Users in the SAFE Study, Baltimore, MD, 1990-1991 a

Variables B SE B ~ F p

Own residence -.32 .23 -.05 1.97 .161

Friends' residence .51 .18 .11 8.03 .005

Shooting gallery .55 .14 .16 15.11 <.000

Mother's residence .13 .14 .04 0.85 .357

Semipublic space b .18 .14 .06 1.94 .165

Injecting with others (continuous) .13 .03 .16 16.39 <.000

Daily use of cocaine or heroin .56 .13 .17 19.95 <.000

Gender (Male:Female) -.20 .16 --.05 1.56 .213

Age (continuous) .02 .01 .08 3.80 .052

Education (<12th:12+) --.19 .12 --.06 2.53 .114

Arrested in prior 10 years --.15 .15 -.04 1.10 .295

Homeless in prior 10 years .26 .12 .08 4.21 .041

Public assistance in prior 10 years .02 .16 .01 0.02 .895

a Missing data on 7 participants. b Street, park, car, rooftop, public bathroom, abandoned building.

As the third dependen t variable, "always clean used needles ," was d icho tomous , a mult iple logistic regress ion mode l was employed . T h e mul t ip le log i s t i c regress ion mode l allows for an analysis of the inde- p e n d e n t associat ion of each independen t var iable with the d e p e n d e n t variable. As seen in Table VI, two settings were significantly negatively associated with repor ts of always cleaning used needles: par t ic ipants who repor t ed injecting at fr iends ' residences were 1.7 t imes m o r e likely to repor t they did not always clean their used needles, and par t ic ipants who repor t ed injecting in semipublic areas were 1.6 t imes more likely to r epo r t not always cleaning used needles. In this mode l injecting in shoot ing galleries was marginal ly negat ively associa ted with always c leaning used needles (p < .06). As multiple logistic regression controls for o the r variables in the model , these results indicate tha t injecting in semipubl ic spaces and fr iends ' residences are independen t risk factors for not always cleaning used needles.

426 Latkin eta/.

Table V. Multiple OSL Regression Analysis of Recency of Sharing Unhygienic Injection Equipment for Injection Drug Users in the SAFE Study, Baltimore, MD, 1990-1991 a

Variables B SE B [$ F p

Own residence .03 .26 .00 0.01 .924

Friends' residence .60 .21 .11 8.01 .005

Shooting gallery .43 .16 .11 6.72 .010

Mother's residence .04 .17 .01 0.07 .790

Semipublic space b .42 .16 .11 7.11 .003

Injecting with others (continuous) ,13 .04 .16 11.44 <.001

Daily use of cocaine or heroin .38 .15 .10 6.85 .009

Gender (Male:Female) -.06 .19 -.01 0.12 .734

Age (continuous) .03 .01 .11 7.18 .008

Education (< 12th:12+) -.19 .14 -.05 1.73 .188

Arrested in prior 10 years -.18 .17 -.04 1.18 .279

Homeless in prior 10 years .34 .14 .09 5.47 .020

Public assistance in prior 10 years .28 .19 .06 2.31 .129


DISCUSSION

In this sample of drug users, injecting cocaine and heroin was a highly social behavior; the majority of participants reported that they injected drugs with others more than half the time. Frequency of injecting with others and attendance at specific injection settings were inde- pendently associated with HIV-related injection practices. Reports of injecting at friends' residences, shooting galleries, and semipublic areas were found to have statistically significant associations with risky injection practices.

There are several plausible explanations for these results. One explanation is that of differential association, that is, high-risk individuals may associate with other high-risk individuals in specific behavior settings

Risk Factors for HIV-Related Injection Practices

Table VI. Multiple Logistic Regression for Always Clean Used Needles for 630 Injection Drug Users in the SAFE Study, Baltimore, MD, 1990-1991 a

427

Variables B SE B OR p

Own residence -.08 .32 0.92 .794

Friends' residence .54 .26 1.71 .042

Shooting gallery .38 .20 1.47 .057

Mother's residence .25 .20 1.29 .214

Semipublic space b .45 .19 1.57 .018

Injecting with others (continuous) .16 .06 1.18 <.001

Daily use of cocaine or heroin .14 .18 1.15 .439

Gender (Male:Female) -.34 .23 0.71 .142

Age (continuous) .02 .01 1.02 .232

Education (<12th:12+) .09 .17 1.10 .587

Arrested in prior 10 years .18 .21 1.20 .389

Homeless in prior 10 years .49 .18 1.64 .005

Public assistance in prior 10 years -.03 .23 0.97 .905


(e.g., shooting galleries). A second explanation is that in some settings (e.g., abandoned buildings, cars, and rooftops), bleach or alcohol is not routinely available. This lack of disinfectants may be a result in part of an absence of a designated individual or role in the setting to specifically maintain a supply of bleach or alcohol to clean injection equipment. A third explanation for the associations found is that of situational norms of role behavior contingent on the social status or power relations of individuals within specific settings. For example, at friends' residences injectors may feel that they are visitors and must share their drugs and injection equipment with the owner m a person of high status in that setting. Refusing to share with higher status individuals may be perceived as breaking a norm and result in sanctions. Individuals also may not feel comfortable engaging in new behaviors, such as cleaning needles before injecting, in unfamiliar surroundings. Specific settings may also serve to cue individuals to engage in certain behaviors.

428 Latkin et al.

Previous studies have found relationships between settings and factors of quality of life, drug treatment outcome, psychiatric symptoms in mental hospitals, and quantity of alcohol consumed (Klassen, 1977; Perkins & Baker, 1991; Schoggen, 1983, 1989; Wigmore & Hinson, 1991). Several authors have elaborated and expanded on Barker's original framework of behavior settings (Kaminski, 1982; Moos, 1983; Wicker, 1979, 1984, 1987). The most detailed critique and revision of behavior settings is Wicker's chapter in the Handbook of Environmental Psychology (1987). Wicker's expanded framework emphasizes the social construction (Berger & Luckmann, 1967) of social interactions and the importance of motives and social cognitions, such as scripts (Abelson, 1981) and social episodes (Forgas, 1979). The present study suggests that settings are indeed useful targets for behavioral research.

One potential limitation of the study is that the sample comprised volunteers for a prevention study who reported sharing drugs in the prior 6 months. Volunteers may differ from those who did not choose to volunteer, or who withdrew from the study, and individuals who report sharing drugs may be more likely to inject in social settings as compared to drug users who do not share drugs. The sample was recruited primarily by word-of-mouth, which may have further restricted the sample variability and therefore the generalizabiltiy of these findings. Ano the r limitation is that the study was cross-sectional, and therefore no causal inferences can be confidently made. As these results are from self-report data there is the possibility that they were influ- enced by socially desirable responding (Latkin, Vlahov, & Anthony, 1993). Moreover, the extent that participants' conceptions of sharing, cleaning, and slipping differ from those of the researchers may bias their reports of injection behaviors.

As with other disadvantaged and difficult to reach populations, it is not easy to characterize the representativeness of a specific sample due to the lack of a population frame (Breakey & Fischer, 1990; Watters & Biernacki, 1989). The present sample of inner-city injection drug users was a nontreatment sample. Yet, older and male injection drug users ap- peared to be overrepresented. It is likely that drug users who are more affluent (e.g., those who deal drugs) were less inclined to participate in the study.

No twi th s t and ing these l imita t ions , this s tudy suggests tha t HIV-related behaviors may differ by environmental settings. Researchers who design risk reduction interventions need to be cognizant of these environmental factors. Systematic study of drug behavior settings, such as the taxonomies of shooting galleries initiated by Ouellet et al. (1991), could contribute to an understanding of the social dynamics of risk behaviors,

Risk Factors for HIV.Related Injection Practices 429

which may facilitate more effective intervention strategies. The findings of associations between settings and HIV-related behaviors has implications for preventive interventions. Street outreach AIDS educators and others who work in community settings might profit from information on behavior settings more appropriate for intervention, or, if behavior in existing settings appears difficult to modify, they could facilitate safer settings. As over 90% of injection drug users in the present study report injecting at friends' residences, HIV prevention interventions targeting friends who inject together may be an important risk reduction strategy for this group.

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My place, your place, and no place: Behavior settings as a risk factor for HIV-related injection...

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