HIV-Risk Behaviors of Sterilized and Nonsterilized Women in Drug-Treatment Programs -- Philadelphia, 1989-1991

From June 1981 through December 1991, 34% of all reported cases of acquired immunodeficiency syndrome (AIDS) among women in the United States were attributed to heterosexual transmission, and that proportion has been increasing steadily (1). Factors associated with an increased risk for heterosexual transmission include unprotected sexual intercourse (2), multiple sex partners, and the presence of other sexually transmitted diseases (STDs) (1). Women who have been surgically sterilized and who are sexually active and/or use injecting drugs may need the same prevention services for human immunodeficiency virus (HIV) and other STDs as similar nonsterilized women; however, the specific needs of sterilized women have not been well characterized. This report compares findings from surveys of surgically sterilized and nonsterilized women in drug-treatment programs in Philadelphia on their drug use and HIV/STD-risk behaviors and assesses changes in risk behaviors among these women after a 9-month period during which family-planning counseling and/or gynecologic services were offered.

The Family Planning Council of Southeastern Pennsylvania, in collaboration with CDC, developed two HIV/STD-prevention and family-planning services; the programs provided either counseling and referral or counseling and gynecologic services to women in 13 drug-treatment programs in Philadelphia. The counseling/referral service offered women in nine drug-treatment centers HIV/STD-prevention messages, family-planning counseling and education, distribution of condoms and nonprescription contraceptives (e.g., contraceptive sponge), and referrals for medical services. In addition to the services listed, the counseling/gynecologic service offered women in the remaining four centers on-site medical examinations, prescription contraceptives, and laboratory tests (e.g., Papanicolaou (Pap) smears, serologic tests for syphilis, cultures for gonorrhea and Chlamydia trachomatis, and wet-mount preparations for vaginitis and cervicitis). In 13 drug-treatment programs, investigators used survey instruments to measure AIDS-related knowledge, attitudes, and behaviors of 492 women who were not pregnant, not menopausal, and agreed to participate in the surveys. Baseline and 9-month follow-up interviews were conducted from April 1989 through January 1991. Trends were determined and statistical differences calculated using chi-square and differences-of-means t tests.

Of the 492 participants, 137 (28%) reported having had an operation that would keep you from getting pregnant, like having your tubes tied, sterilization, or hysterectomy. Sterilized women in the drug-treatment programs were more likely than nonsterilized women to be older (average age: 37 years (standard deviation (SD)=plus or minus 6.8 years) versus 33 years (SD=plus or minus 6.0 years)) and to have fewer years of education (51% and 40%, respectively, had not completed high school). Sterilized women reported ever having had pelvic inflammatory disease more often than nonsterilized women (34% versus 23%). Sterilized and nonsterilized women in this study were not significantly different with regard to ethnicity.

Of the 248 (50%) women who had been tested for HIV antibody, three (5%) of the sterilized, and seven (5%) of the nonsterilized women were HIV-antibody-positive. Sterilized women were slightly more likely than nonsterilized women to have ever been injecting-drug users (IDUs) (74% versus 65%; p=0.08) (Figure 1). A substantial proportion of women had used injecting drugs during the 4 weeks before their baseline interviews (40% of the sterilized versus 33% of the nonsterilized women (p=0.16)). Approximately one third (55) of those who were IDUs reported using their partners' or others' needles.

Most women were sexually active during the 4 weeks before the baseline interview (70% of the sterilized versus 60% of the nonsterilized). Fewer sterilized women than nonsterilized women had ever used condoms (55% versus 66%; p=0.02), and fewer sexually active sterilized women reported any condom use during the 4 weeks before the baseline interview (12% versus 28%; p=0.001). * HIV risks related to multiple partners or to exchanging sex for drugs or money did not differ statistically between the two groups. Risk status of their primary sex partners ** was similar for both groups of women; 190 (49%) had partners who had been in prison, and partners of 226 (58%) were IDUs.

At their baseline interview, fewer sterilized than nonsterilized women reported ever attending a family-planning clinic for birth control (38% versus 58%) and most sterilized women (65%) did not report perceiving a need to visit a family-planning clinic. However, in the 9-month interval between their baseline and follow-up interviews, 69% of the sterilized women and 73% of the nonsterilized women used the on- or off-site HIV/STD-prevention and family-planning services offered.

Results at the 9-month follow-up interview indicated that both sterilized and nonsterilized women had made slight changes in their HIV-risk behaviors, including condom use. The difference in condom use between sterilized and nonsterilized women remained substantial (13% versus 34%; p less than 0.001). Reported by: KA Armstrong, MS, L Samost, Family Planning Council of Southeastern Pennsylvania, Inc, Philadelphia; DR Tavris, MD, State Epidemiologist, Pennsylvania Dept of Health. Behavioral and Prevention Research Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Although pregnancy and perinatal transmission of HIV are not concerns for sterilized women in drug-treatment programs, their personal risks for HIV/STD infection are substantial. Most sterilized women in this study perceived no need for family-planning services, yet when on-site family-planning counseling and gynecologic services were provided at drug-treatment programs, both sterilized and nonsterilized women used the services. Family-planning providers offer screening for STDs, Pap smears, HIV education, and contraceptive services (e.g., condom distribution) -- services that are needed by both sterilized and nonsterilized women. Publicly funded family-planning programs are experienced in providing a wide range of services to women and should be encouraged to 1) extend services to settings where women who are at increased risk for HIV infection may be reached and 2) inform women that these services provide a number of disease-prevention, educational, and gynecologic services that are important and available even to women who have been sterilized.

Although the sample findings from the survey in Philadelphia provided new information on the risks and behavioral changes of sterilized and nonsterilized women in drug-treatment centers, these results may not be readily generalized to all sterilized women or women at risk for HIV infection not in drug-treatment centers. Despite this limitation, the results of this demonstration project show that it is possible to provide family-planning counseling and HIV-prevention and gynecologic services in drug-treatment programs to women at increased risk for HIV/STD infection. In addition, although reductions in HIV-related risk behaviors, including condom use, were small for both groups of women at the 9-month assessment, follow-up assessments at 15 months are needed. Special efforts may be needed to reach sterilized women with appropriate prevention services; however, with better characterization of HIV/STD behavioral risks for diverse groups of women, targeted prevention efforts can be developed to reduce risks among these groups.

Providing preventive services, including on-site medical services as well as counseling and referral to appropriate off-site service providers (e.g., drug-treatment programs) may be an important step in meeting the national health objectives for the year 2000 for HIV-infection prevention (objective 18.2) (3). Therefore, continuing assessment of women participating in this program and further application and evaluation of similar services in other geographic areas are needed.

References

1. CDC. The second 100,000 cases of acquired immunodeficiency syndrome -- United States, June 1981 - December 1991; MMWR 1991;41:28-9.

2. Fischl MA, Dickinson GM, Scott GB, Klimas N, Fletcher MA, Parks W. Evaluation of heterosexual partners, children and household contacts of adults with AIDS. JAMA 1987;257:640-4.

3. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives--full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

• Sterilized women were five times less likely to use condoms than were nonsterilized women when controlled for age, education, ethnicity, main partner, attempts to become pregnant, sex for money during last 4 weeks, ever having had an STD, and belief that condoms are the best way to prevent STDs (adjusted odds ratio=5.24; standard error=0.44). ** Participants indicated whether they considered any particular sex partner a primary sex partner.

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