Differential Drug Use, HIV/AIDS, and Related Health Outcomes
Among Racial and Ethnic Populations: A Knowledge Assessment Workshop
April 26-27, 2001
Workshop Purpose
A workshop on "Differential Drug Use, HIV/AIDS, and Related Health Outcomes Among Racial and Ethnic Populations: A Knowledge Assessment Workshop," was held April 26-27, 2001, in Bethesda, Maryland. The National Institute on Drug Abuse (NIDA) sponsored the workshop with support from the Office of Research on Women's Health. The overall goal of the workshop was to critically examine current knowledge about disparate drug use, HIV/AIDS, and associated social, medical, and health consequences within and across racial and ethnic minority populations. The meeting was a joint effort of NIDA's Epidemiology Research Division and the Center on AIDS and Other Medical Consequences of Drug Abuse (CAMCODA).
Workshop Objectives
- To assess current knowledge of disparate drug use and related social, medical, and health consequences within and across racial and ethnic populations.
- To assess current knowledge and research gaps related to other disparate acquisition and transmission of HIV/AIDS, hepatitis B (HBV), hepatitis C (HCV), tuberculosis, and other infectious diseases within and across racial and ethnic drug-using populations.
- To identify and assess risk and protective factors and their influences on disparate drug-use patterns and related health disparities within and across racial and ethnic populations.
- To delineate a research agenda to address research gaps pertaining to drug-related health disparities across racial and ethnic groups in epidemiology, etiology, prevention, treatment, and services research.
Workshop Format and Process
The 2-day workshop consisted of seven panels organized around different themes related to health disparities. Presentations were held on the first and second days of the workshop. On the afternoon of the second day, workshop participants were separated into two groups to identify research gaps and potential research priorities.
Day One: April 26, 2001
Panel 1. Health Disparities Among Racial and Ethnic Populations:
Theoretical Frameworks and Conceptual Models Guiding the Research
Moderator: James Hildreth, M.D., Ph.D.
Panelists: Stephen Buka, Ph.D.; and Raynard Kington, M.D., Ph.D.
Over the past century, there have been improvements in health status across racial and ethnic populations, genders, and age groups. Despite these improvements, there are persistent, and in some cases, widening, gaps in health status across population groups. Racial disparities also exist in access to and utilization of health care services. Infant mortality rates, which are considered good overall health indicators, vary dramatically among different racial and ethnic populations.
Differences in health status within and across racial and ethnic groups have been associated with socioeconomic status (SES), psychosocial factors, quality of and access to health care, health behaviors, cultural and ethnic identity, acculturation, racial discrimination, segregation, and environmental and occupational stresses. Although many of the differences in health outcomes are probably determined by SES, it is not the whole explanation. Researchers want to know the extent to which these disparities are driven by socioeconomic opportunities for racial and ethnic minorities and the extent to which there are pathways independent of SES. Complicated models involving the interrelationships among SES, ethnic identity, culture, and discrimination are key to understanding the adolescent progression part of disparities in substance use and abuse.
Panel 2. Differential Drug Use Patterns Within and Across
Racial and Ethnic Populations
Moderator: Coryl Jones, Ph.D.
Panelists: Frederick Beauvais, Ph.D.; Sean F. Reardon, Ph.D.;
John M. Wallace, Jr., Ph.D.; and Rumi Price, Ph.D.
According to recent National Household Survey data, rates for the use of illicit drugs, nicotine, and alcohol, are highest among American Indians, followed by Whites and Hispanics. Drug use was reported to be lowest among African Americans and Asian Americans. While substance abuse is a problem in all population groups, its social and health consequences are more heavily concentrated among racial and ethnic minority populations, and African Americans in particular. The health consequences of drug use (i.e.HIV/AIDS, lack of treatment access, emergency room visits, and death) disproportionately impact African Americans. The extent to which social and health consequences vary within and across ethnic groups and causes of the variance remains to be understood. To help understand this, research is needed that focuses on within-group heterogeneity that exists in Hispanic-Latino, Asian American, African American, and White populations. Reported rates of drug use among high school seniors in the Monitoring the Future Study varied among the Hispanic subgroups, including Cubans, Mexicans, Puerto Ricans, and other Latinos. A conceptual framework is needed to link macro-structural risks and protective factors, including neighborhood and interpersonal and individual risks.
Distinct regional differences in adolescent drug use across the country need to be addressed before interventions can be developed. Socioeconomic and demographic factors associated with neighborhoods need to be understood. For example, American Indian adolescents living on reservations seem to have higher rates of drug use than their counterparts who live off of reservations. Researchers need to understand the influence of social, economic, and other factors driving the differences in drug use rates between these two groups.
Perceived discrimination leads to high levels of anger and delinquent behavior, which often leads to drug use. Perceived discrimination also leads to depression and anxiety. Some studies have found no correlation between cultural identification and levels of drug use among adolescents. On the other hand, adolescents with "high Indian" cultural identification report higher levels of discrimination yet perform better in school and have lower rates of drug use. A prospective, multisite, study in Chicago has shown that there is something protective for adolescent cigarette and alcohol use related to living in a predominantly African-American neighborhood.
Reliable national data on substance use and abuse among Asian Americans and Pacific Islanders (AAPIs) in the United States is limited. Local data suggest that there has been an increase in substance use among AAPI subgroups. There are considerable differences in substance use across the five largest AAPI subgroups (Japanese, Filipino, Chinese, Korean, and Vietnamese). The Japanese subgroup is the largest, and its rates of drug use are similar to that of Whites. The Vietnamese have the lowest rates of drug use of the five subgroups. Acculturation appears to influence drug use. The decay of AAPI socioenvironmental factors and their protective benefits need to be studied. There is also evidence of genetic influence on substance use among AAPIs. ALDH2 and CYP286 are protective genes that slow the metabolism of alcohol consumption and nicotine, respectively. ALDH2 is found only among the Japanese and Chinese, and CYP286 is more prevalent among Chinese and Japanese than among other AAPI subgroups.
Does neighborhood context explain any of the disparities in drug use? According to a Chicago study, the answer is Yes for disparities between African Americans and Whites, and No for disparities between Hispanics and Whites. There are racial and ethnic differences in abuse and dependence symptoms, rates of drug use onset, and the persistence of dependence symptoms between the ages of 18 and 20. At age 18, there are higher rates of substance use for Whites and lower rates of use for African Americans and Hispanics. This was true regardless of which substance was examined, and when the analysis was controlled for SES. At age 20, there was a reversal; African American drug use rates increased, and White rates decreased. What is the explanation for the protective effect of African American neighborhoods with regard to adolescent drug use and the difference in onset rates? One explanation is that there is a factor at work in the neighborhood context. Another is that African American adolescents encounter fewer opportunities after high school compared with their White and Hispanic counterparts; therefore the likelihood of their using drugs after high school is greater.
Panel 3. Adverse Social and Health Consequences Among
Racial and Ethnic Drug Users
Moderator: Yonette Thomas, Ph.D.
Panelists: Martin Iguchi, Ph.D.; William Vega, Ph.D.; and Sandro Galea, M.D.
Research on early adolescent risk factors for drug abuse among African Americans and Whites in Dade County, Florida, has shown a phenomenon of late onset of drug use among African Americans, even though they have higher risk-factor averages overall. Research indicates that diverse racial and ethnic populations have also reported similar variance patterns in risk factors for substance abuse within populations. The protective factors responsible for the late onset of alcohol and marijuana use among African Americans need to be researched. Possible protective factors include the family, extended family, and social support processes in African-American households.
Adverse health consequences related to drug use include homelessness, imprisonment, discrimination, unemployment, low socioeconomic status, HIV infection, and high mortality. Mortality from drug-related illnesses has been associated with HIV infection, which is common among drug users, a history of incarceration, and unemployment. Drug users report that the greatest discrimination they experience is due to their drug use and, among those with convictions, having a prison record. Interventions need to be developed for high-risk and imprisoned drug users to reduce poor health consequences.
The U.S. government's war on drugs has had a disproportionate impact on racial and ethnic minority communities. Prison drug admissions have increased 16-fold since 1983, and a disproportionate number of those incarcerated are African Americans. In 1999, 1.5 million African-American children under 18 years of age had a parent living in prison. More than 50 percent of the Hispanic women incarcerated have been convicted of a drug offense. A felony conviction makes one ineligible for Federal benefits; a drug conviction endangers housing and education benefits. Prison does not help to reduce individual drug use, and once a person returns to the community, he or she usually begins using drugs again. There needs to be increased availability of drug treatment services in prison for this cycle to stop.
Panel 4. Gender Differences and the Dynamics of HIV/AIDS
Among Racial and Ethnic Populations
Moderator: Loretta Finnegan, M.D.
Panelists: Kathy Sanders-Phillips, Ph.D.; and Ellie Schoenbaum, M.D.
Research shows that the primary route for HIV infection among women is injection drug use, prostitution, sex with an injection drug user (IDU), and sex with a man who has been incarcerated. Women drug users exchange sex for drugs or money, but they are likely to be in a monogamous relationship. Current data strongly suggest that women drug users are likely to be depressed and isolated, and rates of drug use increase as women are marginalized. This pattern has been identified for all groups, but it is exacerbated by racial and ethnic minority status. Men have a significant impact on women's drug use outcomes, but women do not affect men's drug use outcomes. A woman's willingness and ability to protect herself against HIV are directly related to her self-power. Condom use is a social statement of power and self-respect that is difficult for most women on the street to assert. Women who feel powerless are not able to protect themselves from HIV infection. Traditional social expectations make it difficult for Latinas to negotiate safe sex with their partners, and a fear of violence inhibits their attempts to negotiate condom use.
There are important differences by race, ethnicity, and gender with regard to access and adherence to standard antiretroviral treatment for HIV infection. One epidemiologic study of HIV progression and outcomes among approximately 1,700 IDUs found that only two-thirds of the men in the study and 60 percent of the women were receiving highly active antiretroviral therapy (HAART). Only 45 percent of African Americans, 52 percent of Hispanics, and 73 percent of Whites complied with the prescribed HAART regimen over a 6-month period. This is a disturbing fact given that these medications have to be taken at high levels to reduce the HIV viral load. Women IDUs were less compliant than men in taking the medications, and rates of hospitalization were higher among women than men.
Panel 5. Risk Behaviors Contributing to the Spread of HIV/AIDS, HBV, HCV,
TB, and Other Infectious Diseases Among Racial and Ethnic Drug Users
Moderator: Jagjitsing H. Khalsa, Ph.D.
Panelists: Lauren V. Wood, M.D.; Tooru Nemoto, Ph.D.;
and Antonio L. Estrada, Ph.D.
Injection drug use is the source of most HCV and HBV transmission in the United States. HIV, HCV, and HBV disproportionately affect racial and ethnic minority populations, particularly African Americans and Hispanics. Health care utilization barriers must be addressed for IDUs to obtain the necessary health care. Syringe exchange programs (SEPs) can facilitate access to social and health services and dramatically alter the risk of blood-borne infections in these populations. Behavioral interventions need to target the risk factors that lead to the spread of blood-borne pathogens among IDUs in racial and ethnic minority populations.
A potential time bomb exists among adolescents in terms of drug use, sexual activity, and HIV/AIDS. Adolescents infected with HIV through high-risk sexual and drug-related behaviors are an emerging group that is changing the HIV/AIDS epidemic. The changing epidemiology of adolescent HIV infection is a consequence of sexual behaviors, which are influenced by drug use. Between 1989 and 1999, a reversal occurred in the ratio of HIV infection among men and women, which means that many more women than men are being infected. HIV prevalence is now higher among women than men for the age groups 13-19 and 20-24. This reversal reflects the increasing heterosexual transmission of HIV, which is now the major route of transmission. Research is needed on drug use behaviors among adolescents in the context of sexual behaviors. These data must be obtained quickly so that intervention programs can be established to stop the spread of HIV/AIDS among adolescents.
AAPIs, particularly AAPI immigrants, are generally less informed about HIV/AIDS than other racial and ethnic populations. One study that researched HIV/AIDS risk behaviors involved bilingual AAPI outreach workers/interviewers who conducted interviews at a local store. They obtained information on the types of drugs people were using, routes of administration, protective and risk behaviors, HIV/AIDS risk behaviors, and sexual behaviors. Female AAPI drug users are at higher risk of HIV/AIDS infection than males. Two-thirds (64 percent) of the men reported having had sex with a prostitute. Ten women reported trading sex for money or drugs. Twenty-eight percent of the sample reported having injected drugs at least once in their lives, and 89 percent reported having used condoms. Psychological and cultural factors specific to AAPIs are related to drug use, and cultural constraints, i.e., shame about drug use and fear of community stigma, can be incorporated into HIV/STD prevention programs.
Day Two: April 27, 2001
Panel 1. The Influence of Culture, Family, Community, and Spirituality
on Drug Use and Related Consequences Within and Across
Racial and Ethnic Populations
Moderator: Arnold R. Mills, M.S.W.
Panelists: Noreen Mokuau, D.S.W.; and Karina L. Walters, Ph.D.
Substance use risk factors for Hawaiian children include family substance use, community substance use, poverty, and colonization. The majority of adults involved with Hawaii's child protective services program have serious substance abuse problems. Commonly used interventions are individual and family/group counseling, parent education, foster care, and crisis intervention. These interventions incorporate selected protective factors, such as spirituality, family support, community efforts, and honoring diversity in cultural values and practices. It is important to develop and use culturally competent approaches to research and intervention programs. These programs emphasize the person's self-esteem and power rather than the substance use. There is value and merit to the scientific method, but it is necessary to incorporate and translate the community's needs so that appropriate measurements can be made.
Fewer than 12 studies related to HIV/AIDS have been conducted among American Indians, who are undercounted in terms of the infection rates. Important factors are culture, spirituality and religiosity, community and family, and traumatic experiences, including historical trauma. Historical trauma includes the American Indians' experience of having their religious practices, involuntary sterilization, and forced attendance at boarding schools. Key themes for researchers to understand in working with the American Indian population are colonization, indigenism, and the movement from treating to healing in partnership with the community. Research must be done in partnership with the community, or it will not succeed. Practice and healing issues include the spirit of medicine, indigenist treatment models that incorporate the dual nature of alcohol, and the idea of offering up suffering. Colonization involves the experience of historical trauma, such as ethnocide and genocide, and is a major factor in the American Indian population. Cultural trauma outcomes include Colonial Stress Disorder and unresolved grief and mourning. A Post-Colonial Stress-Coping model for interventions acknowledges the associations between stressors and adverse health changes, and these associations are moderated by cultural factors, which can function as buffers. Stressors include historical trauma, microaggression, loss, and ethnocide, and buffers include culture, family, community, and spirituality. Research is needed on the ongoing, cumulative and intergenerational effects of trauma, including alcohol and other drug use and related consequences. Interventions need to be developed that focus on enculturation and affirming the American Indian culture's values as opposed to interventions based on acculturation to outside cultures.
Panel 2. Effective Interventions: Preventing Drug Abuse
and the Spread of HIV/AIDS
Moderator: Deborah M. Smith, M.D., M.P.H.
Panelists: Debra Jones-Sumty; Faye Belgrave, Ph.D.; and Claire Sterk, Ph.D.
Risk factors for HIV/AIDS infection among American Indians include alcohol and substance abuse, particularly among young people; unprotected sexual activity; poverty; and high unemployment (90 percent) within communities and tribes. Another risk factor is the lack of confidentiality about health issues, particularly in small communities. Alcohol and injection drug use are the major risk factors or HIV infection, and injection drug use is increasing among American Indians, including the injection of methamphetamine. There is distrust of health care institutions and denial of the prevalence of HIV/AIDS, which people still consider being primarily a disease of gay men.
No single HIV/AIDS intervention will work for every American Indian tribe. There has to be a community-by-community approach to intervention development. For interventions to be effective, they must be culturally and community-specific, use local resources, and be consistent with the community's readiness to address the problem. The Community Readiness Model outlines stages of community readiness and offers guidelines for working with American Indian communities. The model is a research and evaluation tool to assess changes in readiness and a community diagnostic tool to identify what interventions are appropriate for particular levels of readiness. It was designed for use with alcohol and drug problems, but it can also be used to address a variety of social and health problems. Effective prevention requires collaboration with all sectors of the community, including the initial assessment, surveillance period, and program implementation.
Early sexual activity has increased among urban African-American adolescents. Adolescent girls who become sexually active early in life, i.e., before the age of 16, are at high risk of sexually transmitted diseases because they are less likely to use condoms and are more likely to have multiple partners. African-American girls have low rates of drug use, but they are often involved with males who have higher rates of drug use. A number of studies have shown that for African-American females, ethnic identity is associated with academic achievement, decreased drug use, and decreased sexual activity. African-American females also put a strong emphasis on relationships, and this is derived from gender and ethnicity. Empirical and conceptual research with African-American females has shown the relevance and congruence of a relational approach to interventions. Pilot data from a current intervention being tested among sixth-grade females show that drug refusal and sexual refusal increased from the beginning of the project to 6 months after it started. The relational and culturally enhanced intervention includes Life Skills training along with female- and Afro-centered components.
Researchers need to start thinking about a conceptually different way to identify protective factors and to focus on risk factors related to the individual, household, and community because they are all strongly connected. Many intervention programs do not acknowledge where a person is in his/her drug use, what role drug use plays in daily life, and what kind of services are needed. The general media campaigns for preventing HIV/AIDS target people at risk, but they do not link with the drug abuse prevention efforts. To be able to discuss racial and ethnic disparities, operational definitions for race and ethnicity need to be determined. When discussing individuals and communities at risk, and community-based interventions, one has to consider the "ecological concentration" of health and social issues and resources, which vary from community to community. This acknowledges that a significant inequality exists among multiple dimensions of resources. Collective efficacy, in which reciprocal obligations develop between community members, is another concept that could play a role in intervention and prevention efforts.
Discussion of Research Gaps and Future Research Priorities
The participants met in groups to discuss gaps in the research field's knowledge about health disparities and recommendations for future research.
- Current methodologies need to be adapted, and new measurement methodologies need to be developed that are culturally relevant and can be used to measure community-based factors, e.g., discrimination and trauma.
- Instruments need to be developed to measure individual and community characteristics. Adult instruments may be adapted for adolescents.
- There is a major gap in research on the context in which interventions are carried out. A mechanism is needed to examine the context in which interventions take place to avoid a mismatch.
- More research is needed on the transition period from adolescence to young adulthood (17-25 years of age). Studies need to be coordinated with other institutions because there may be some overlap, e.g., with the National Institute on Alcoholism and Alcohol Abuse.
- What cultural buffers and protective factors exist within each population?
- What are the stresses and risk behaviors for each population?
- What family- and community-based factors are specific to different populations?
- How accessible is drug treatment for different racial and ethnic population groups? What are the differences in terms of how services are utilized, including prevention services?
- How can the processes facilitating access to and utilization of treatment services be applied in a prevention mode?
- What is the impact of intergenerational trauma?
- Exposure-based thinking and research (as opposed to outcome-based) is needed to examine the impact of discrimination and other social factors and influences.
- What happens to people after they are released from prison and sent back into the community? What is the impact regarding health, social, gender, and class issues? What is the impact between and within racial and ethnic population groups?
- We need collaborative research, starting with collaboration with the community.
- Mechanisms are needed to facilitate new and creative approaches to studying different cultures. Specifically, it was suggested that a period of time should be set aside before a study begins for researchers to meet the community, develop a rapport with community members, and become cognizant of the key people and issues facing the community.
- We need to build research capacity to facilitate examining smaller American Indian tribes and smaller population groups.
- More mediational models are needed that have clearly defined constructs and methods of measurement. Cultural parameters need to be examined within mediational models.
- We need to change our thinking about research modelsÑhow can we better utilize them with communities?
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