Table Of ContentSocial Networks,
Drug Injectors’ Lives,
and HIV/AIDS
AIDS Prevention and Mental Health
Series Editors:
David G. Ostrow, M.D., Ph.D.
Howard Brown Health Center and University of Illinois/Chicago School
of Public Health, Chicago, Illinois
Jeffrey A. Kelly, Ph.D.
Center for AIDS Intervention Research (CAIR), Milwaukee, Wisconsin
Evaluating HIV Prevention Interventions
Joanne E. Mantell, Ph.D., M.S.P.H., Anthony T. DiVittis, M.A.,
and Marilyn I. Auerbach, A.M.L.S., Dr. P.H.
Handbook of Economic Evaluation of HIV Prevention Programs
Edited by David R. Holtgrave, Ph.D.
Methodological Issues in AIDS Behavioral Research
Edited by David G. Ostrow, M.D., Ph.D., and Ronald C. Kessler, Ph.D.
Preventing AIDS: Theories and Methods of Behavioral Interventions
Edited by Ralph J. DiClemente, Ph.D., and John L. Peterson, Ph.D.
Preventing HIV in Developing Countries:
Biomedical and Behavioral Approaches
Edited by Laura Gibney, Ph.D., Ralph J. DiClemente, Ph.D.,
and Sten H. Vermund, Ph.D., M.D.
Psychosocial and Public Health Impacts of New HIV Therapies
Edited by David G. Ostrow, M.D., Ph.D., and Seth C. Kalichman, Ph.D.
Social Networks, Drug Injectors’ Lives, and HIV/AIDS
Samuel R. Friedman, Ph.D., Richard Curtis, Ph.D., Alan Neaigus, Ph.D.,
Benny Jose, Ph.D., and Don C. Des Jarlais, Ph.D.
Women and AIDS: Coping and Care
Edited by Ann O’Leary, Ph.D., and
Lorretta Sweet Jemmott, R.N., Ph.D., F.A.A.N.
Women at Risk: Issues in the Primary Prevention of AIDS
Edited by Ann O’Leary, Ph.D., and Loretta Sweet Jemmott, R.N., Ph.D.
A Continuation Order Plan is available for this series. A continuation order will bring delivery of
each new volume immediately upon publication. Volumes are billed only upon actual shipment.
For further information please contact the publisher.
Social Networks,
Drug Injectors’ Lives,
and HIV/AIDS
Samuel R. Friedman, Ph. D.
National Development and Research Institutes, Inc.
New York, New York
Richard Curtis, Ph. D.
John Jay College of Criminal Justice
New York, New York
Alan Neaigus, Ph.D. and
Benny Jose, Ph. D.
National Development and Research Institutes, Inc.
New York, New York
and
Don C. Des Jarlais, Ph.D.
National Development and Research Institutes, Inc.,
Beth Israel Medical Center, and
Albert Einstein College of Medicine
New York, New York
Kluwer Academic Publishers
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Foreword
Friedman, Curtis, Neaigus, Jose, and Des Jarlais in their critically important, and
timely publication on drug injectors’ lives in the Bushwick section of Brooklyn,
New York, combine epidemiological and ethnographic data and introduce social
network concepts and methods to enumerate and explain co-occurring, inter-
related, and epidemics of drug use and HIV/AIDS. The authors provide a historical
perspective on the lives of drug injectors in New York City, the epicenter of HIV/
AIDS in the United States, and the city with the largest AIDS epidemic among
IDUs anywhere in the world. The authors’ crossdisciplinary theoretical perspec-
tives, and the findings from this study create a methodological dialogue between
epidemiological and ethnographic data about HIV/AIDS among drug users con-
tributing greatly to our understanding of the spread and dynamics of HIV transmis-
sion in drug-using populations and the prevention of HIV and other blood borne
infectious diseases, including hepatitis B.
To appreciate the considerable contributions of this book to help us under-
stand drug abuse and HIV transmission as well as the prevention and control of the
spread of HIV, I want to provide a brief contextual perspective on the evolving
science related to HIV in drug-using populations. Earlier in the epidemic, re-
searchers relied on traditional epidemiological methods to help better identify and
enumerate risk behaviors of individuals, the relationship between risk behaviors
(e.g., multiperson reuse of drug injection equipment) and the transmission of
newly emerging infectious diseases, and develop prevention and control strategies
for helping individuals change their behaviors. Friedman and his colleagues are
among a small number of researchers who introduced and contributed to an
expansion of the research paradigm that integrates social network concepts and
methodology with traditional epidemiological methods. They focus on the follow-
ing: the contextual factors-the context or where behaviors occur and the relation-
ship between risk behaviors and the likelihood of acquiring and/or transmitting
HIV infection, and structure and dynamics of drug-using risk networks and
behavioral transaction that link IDUs in drug acquisition, preparation, and the
injection process. They combine quantitative and qualitative data to describe the
context of HIV risk among drug users and their sexual partners in Bushwick. Drug
injectors in Bushwick were recruited through street outreach in areas with heavy
drug use and through chain referral by other participants. They were interviewed
v
vi Foreword
from July 1991 to January 1993, and questions about their life histories, particularly
about their drug-using behaviors, permit the researchers to report on changes in
their patterns of drug use and risk behaviors over time. The authors’ bibliography
is extensive, crediting other researchers for their many contributions to our
understanding of risk networks, drug abuse and HIV transmission, and they are
careful to report the limitations of the methodologies used in their study.
How then have Friedman and his colleagues helped us to better understand
the changing dynamics of the co-occurring and interrelated epidemics of drug
abuse and HIV/AIDS and anticipate the challenges of emerging HIV-related issues
in preventing the spread of HIV? Emerging from this very important study is the
finding that the context of HIV risk, or the settings where risk behaviors occur,
such as crack houses, shooting galleries, and other public high-risk environments,
influence the probability of viral transmission. The compelling narratives of the
everyday lives of drug injectors, describing the dynamics of buying and using
drugs, and changes in the drug scene over the course of the HIV epidemic, help us
to understand how more macro-level factors such as neighbor density, housing,
and the economy affect the lives of injectors, influence the formation, mainte-
nance, and/or dissolution of risk and social networks, and affect their risk behav-
iors and, in turn, the probability of viral transmission. Specifically, context and the
behavioral transaction linking IDUs in the multiperson use of drug injection
paraphernalia (eg., cookers, cotton, and water) and from injection practices
related to transferring drug solution from one syringe to another, as well as
multiperson reuse of syringes, helps account for the dynamics of HIV transmis-
sion. Most importantly, Friedman and his colleagues discuss risk networks, the
location of a person within the network, and the differential probabilities of
engaging in high- and low-risk behaviors. It is their discussion of the concept of
mixing and the findings related to behavioral transaction between HIV seronega-
tive risk network members and HIV seropositive risk network members that helps
the field understand how the merger of the social network paradigm with ethnogra-
phy helps inform our epidemiological concepts of infectious disease transmission.
Friedman and his colleagues had hoped to provide the reader with informa-
tion that can strengthen efforts to conduct useful research and develop or imple-
ment effective prevention programs or policies. They were successful.
This foreword represents the expressed/written view of the author (Richard
H. Needle, Ph.D., M.P.H.) and not of the National Institute on Drug Abuse (NIDA),
National Institutes of Health.
Richard H. Needle, Ph.D., M.P.H.
National Institute on Drug Abuse
Pr efa ce
By early 1989, the senior author of this volume (Sam Friedman) had been working
in the AIDS field for over 5 years. Most of his efforts had been spent in research
based on individualistic models of epidemiology or prevention. Thus, he had
worked on studies at the individual level of analysis of risk factors in HIV infection
among drug injectors in drug abuse treatment (Friedman et al., 1987c; Marmor et
al., 1987); on an experiment to determine whether providing social skills and AIDS
knowledge and referrals to heroin sniffers would help them avoid becoming
injectors (Casriel et al., 1990; Des Jarlais, Casriel, Friedman, & Rosenblum, 1992);
and on an evaluation (with associated epidemiological research) of an AIDS
outreach project that emphasized knowledge and HIV antibody testing and coun-
seling (Friedman et al., 1989a-c;N eaigus et al., 1990). He had also been involved
in helping to establish the World Health Organization Multi-Centre Study on Drug
Injecting and Risk of HIV Infection, including having written the first draft of its
individually oriented questionnaire (Stimson, Des Jarlais, & Ball, 1998). He also
had been a major drafter of the individually oriented questionnaire for the multisite
National AIDS Demonstration Research (NADR) project, which the National
Institute on Drug Abuse sponsored and funded in more than 50 cities in the United
States (Brown & Beschner, 1993). All the authors of this volume were involved in
the Community AIDS Prevention Outreach Demonstration (CAPOD) project,
which they organized as part of NADR. CAPOD, however, contained an effort to
use supraindividual social forces as well as individually focused efforts to encour-
age risk reduction. Specifically, it aimed to use social pressures to “change the
culture of risk,” with a major thrust to help drug injectors establish their own
organizations modeled after the Dutch junkiebonden and other drug users’ unions
(Friedman et al., 1987b, 1988, 1989b) that would attempt to mobilize social
pressures and change norms from within the drug scene to support risk reduction.
CAPOD in fact seems to have led to considerable risk reduction (Friedman, 1991;
Friedman et al., 1991,1992; Jose et al., 1996), although its attempts to organize drug
users’ groups were less than totally successful. Though part of the reason for this is
that the subcontractor that carried out this phase of the project resisted its supra-
individual focus and spent very little time trying to set up drug users’ groups
(Friedman et al., 1991), it is never easy to organize groups “from the outside.”
(Drug users’ organizations have formed themselves in many parts of the world,
vii
viii Preface
including The Netherlands, Australia, and some cities in the United States. Several
years after CAPOD ended, and in part due to our continuing efforts to encourage
users to organize, and AIDS intervention projects to assist in, this effort, users’
groups were established in New York City with the help of syringe exchange proj-
ects in the Bronx and Manhattan’s Lower East Side).
As CAPOD was drawing to a close, our team spent considerable time soul-
searching and trying to figure out how we could most usefully contribute to the
battle against AIDS. It struck us that there were a number of key questions in the
epidemiology of HIV and in the shaping of high-risk behavior and deliberate risk
reduction that needed more study. Particularly salient in our minds were the
following questions:
1. Why are African-American and Puerto Rican drug injectors consistently
more likely to be infected than white drug injectors? These differences
remained in most studies even after statistically controlling for different
levels of risk behaviors (Friedman et al., 1997d, 1998b; Jose, 1996). It
seemed to us that there would likely be two important contributors to
blacks’ and Puerto Ricans’ greater probability of being infected: First,
their social and injecting networks were likely to include primarily other
African Americans and Puerto Ricans. This would mean if their infection
rates were higher or began earlier, they would be likely to continue to
have a higher HIV seroprevalence than whites for some years because the
epidemics in the different racial ethnic groups would be socially sepa-
rated, and thus would follow somewhat different trajectories (Des Jarlais
& Friedman, 1989; Friedman, 1995). These network phenomena might
explain why the epidemics remained semisegregated, but by themselves,
however, would not explain why it was that African Americans and
Puerto Ricans had higher seroprevalence than whites. To explain this, we
looked at a second possible explanatory framework: As the victims of
racial-ethnic oppression and subordination, African-American and Pu-
erto Rican drug injectors would have access to fewer resources than
white injection drug users, and the social organization of both their
neighborhoods and their portion of the drug scene might be shaped by the
stigma and police pressures of oppression in ways that would make it
difficult for them to engage in sustained risk avoidance. This framework,
of course, was rather vague. We hoped, in the course of the research, to be
able to concretize and demonstrate it.
2. How did new injectors come to be infected? Our prior research had
shown that new injectors in New York City were much less likely to be
infected than longer-term injectors, even though they engaged in similar
levels of high-risk behavior (Friedman et al., 1989a). In part, of course,
this was simply a question of exposure time: the longer-term injectors
Preface ix
had engaged in high-risk behaviors for many more years, and thus had
had many more opportunities to encounter HIV. Nonetheless, we were
struck by the fact that if a group of uninfected persons began to inject
drugs, continued to inject and have sex only with others who were new
injectors, and whose circles injected only with others like them, HIV
would never enter their networks and they would remain uninfected. This
meant that new injectors would become infected only as the result of a
social process in which their networks came to interact and intersect with
those of infected persons. The SFHR project aimed, in part, to study this
social process and show how it was related to the spread of HIV infection
among new injectors.
3. How did the social shaping of drug injectors’ risk behaviors take place?
We and others had collected considerable evidence that peer influence
was one determinant of risk behavior (Abdul-Quader, Tross, Friedman,
Kouzi, & Des Jarlais, 1990; Friedman et al., 1987b; Huang, Watters, &
Case, 1989; Huang, Watters, & Lorvick, 1989b; Magura et al., 1989,
1990). We felt it was important to develop a better understanding of how
peer influence operated and how other social influences might shape
risky behavior. In particular, we were impressed by a simple fact that
seemed not to have been incorporated in most other researchers’ theories
or practice: The behaviors that put persons at risk for HIV were always
interactions among two or more persons (Friedman et al., 1990). It is
impossible (other than through physical violence or sneakiness) either to
share syringes or to have unprotected sex with someone who refuses.
Thus, high-risk behavior was a form of interpersonal interaction rather
than a personal characteristic. (To clarify this: A personal behavior is
something like picking and eating a strawberry, which is governed only
by desire and by the availability of strawberries, whereas the interactive
nature of some behaviors is exemplified by the absurdity of trying to
understand the physical gesticulations of a prizefighter without taking
into account the blows and dodging of her or his opponent.) To under-
stand high-risk injecting and sexual behaviors better and to develop more
effective intervention techniques we would have to study behaviors as
characteristics of the relationships between those who were engaging in
the behaviors and also the norms that guided action in their social circles.
These three issues (racial-ethnic difference in seroprevalence, the social
pathways through which new injectors might come to be infected, and the social
shaping of risk behavior) can, in part, be studied by looking at the social networks
and risk networks of drug injectors. Here “social networks” can be understood as
the pattern of social linkages among people, such as friendships, acquaintance-
ships, kinship relations, and more formal relationships such as those with teachers
