1. No category

Diehl, et al., J Addict Behav Ther Rehabil 2014, 3:2
http://dx.doi.org/10.4172/2324-9005.1000120
Journal of Addictive
Behaviors, Therapy &
Rehabilitation
Research article
Sexual Behaviours and Condom
Use in a Sample of Brazilian
Crack Cocaine Smokers
Alessandra Diehl1*, Denise Leite Vieira1, Hussein Rassool G2,
Sandra Cristina Pillon3 and Ronaldo Laranjeira1
Abstract
Crack cocaine smokers exhibit high levels of risky sexual
behaviours. The current study examined a cohort of Brazilian crack
cocaine smokers (n=304) admitted to an addiction inpatient care
unit, assessing the reasons for risky sexual behaviours and their
non-use of condom. Using a drug abuse screening test (DAST)
and semi-structured questionnaires to collect socio-demographic
data and sexual behaviour characteristics, the study showed
that nearly half of the sample, mostly men, never used condoms
or used condoms inconsistently. The main reasons for not using
condoms included steady partner, disruption of sensitivity, and too
much sexual arousal. Gender was the most important variable for
discriminating non-use of condoms. In men, the number of partners
and race were predictors of condom use. In both genders, more
severe dependence was associated with higher rates of non-use
of condoms and sexual activity in the last 12 months. Condom use
is an important issue for the development and implementation of
gender-targeted, culturally appropriate interventions to promote
condom use in crack cocaine smokers.
Keywords:
Crack/cocaine; Condoms; Sexual behaviour; Sexual partners;
Gender
Introduction
The World Drug report shows that about 230 million people,
or 5 per cent of the world’s adult population, are estimated to have
used an illicit drug at least once in 2010. Problem drug users number
about 27 million, which is 0.6 per cent of the world adult population.
Throughout the world, the trend of illicit drug use appears to be
generally stable. Cocaine use has remained stable at 0.3-0.4% of the
population between 13.2 million and 19.5 million users (aged 1564). However, there have been substantial decrease in the prevalence
of cocaine use in North America, but increases in Oceania, Asia,
Africa and some countries in South America [1]. Brazil is currently
considered to be the largest global market for crack cocaine in the
world [2]. Approximately 1.8 million people reported using crack
cocaine during their life, and one million people have used crack
in the past year [2]. However, there is still a considerable lack of
national studies evaluating the use of condoms and other correlates of
sexuality in crack users in Brazil [3]. Injecting drug users (IDUs) have
*Corresponding author: Alessandra Diehl, Rua Botucatu, 394 - Vila
Clementino, 04038-001 - São Paulo - SP, Brazil, Tel/Fax: (55 11) 55795643;
E-mail: alediehl@terra.com.br
Received: February 02, 2014 Accepted: March 27, 2014 Published: March 31,
2014
International Publisher of Science,
Technology and Medicine
a SciTechnol journal
historically received greater attention in studies of condom use and
sexual behaviours in the transmission of sexually transmitted disease
(STIs) and HIV [4,5]. IDUs are at greater risk of developing bloodborne viruses than the general population and many engage in shared
injections and vulnerable sexual behaviours [6-8].
Crack cocaine smokers exhibit high levels of risky sexual
behaviour [9-11]. There are now growing number of newly recorded
cases of HIV infection among females in some countries and this may
be associated with the development of risky sexual behaviours among
female crack smokers [9,12,13], who exchange sex for drugs and let
the partner decide whether to use a condom [14,15]. In a sample of
125 female crack cocaine smokers from impoverished communities
in Salvador, Brazil with a low educational level and high rate of
unemployment (close to 90%), 37% of the females reported trading
sex for money or drugs, and 58% reported that condoms were not
used during intercourse in the last 30 days. Female crack cocaine
smokers are an important risk group regarding the transmission of
STIs [16].
Condom use is an important method of family planning and
prevention STIs, especially HIV/AIDS. Condom use involves
complex social norms and interpersonal dynamics with structural
and cultural conditions framing social cognitions and setting limits
on autonomy that cause the irrational choice of avoiding condoms to
be a rational decision [13,15]. There are distinctly different underlying
cognitive structures of condom use for males and females. A personal
behaviour of condom-use responsibility had a strong direct effect
on the men’s intentions to use condoms with the last sex partner.
The females’ intentions were strongly influenced by personal and
social subjective norms. Inconsistent and incorrect use of condoms
limit the success of condom programs in preventing STIs and HIV
worldwide, especially in vulnerable populations such as drug users
[17-19]. The aim of this study paper is to assess the sexual behaviours
and the non-use of condoms in a sample of Brazilian crack cocaine
smokers admitted to an addiction treatment unit.
Methods
This study involved a cross-sectional design and was conducted at
an inpatient addiction treatment unit in Sao Paulo, Brazil. The sample
comprised consecutive admissions of 304 crack cocaine smokers aged
18 years old or older with a confirmed clinical dependence diagnosis
according to the DSM-IV-TR diagnosis criteria [20]. This study
was approved by the Federal University of Sao Paulo (UNIFESP)
Ethics Committee (protocol number 1193/09), and all the subjects
signed an informed consent form. The patients were interviewed
up to two weeks after admission. Data collection was conducted by
four members of the staff who were previously trained to apply the
questionnaire used in this study.
Questionnaires
Socio-demographic data. The socio-demographic data included
age, educational level, race, marital status, monthly income,
employment status, and religious affiliation. The questions regarding
sexual behaviours included frequency of condom use, number
of sexual partners in the last year, history of sex with sex workers
All articles published in Journal of Addictive Behaviors, Therapy & Rehabilitation are the property of SciTechnol, and is
protected by copyright laws. Copyright © 2014, SciTechnol, All Rights Reserved.
Citation: Diehl A, Vieira DL, Rassool GH, Pillon SC, Laranjeira R (2014) Sexual Behaviours and Condom Use in a Sample of Brazilian Crack Cocaine Smokers.
J Addict Behav Ther Rehabil 3:2.
doi:http://dx.doi.org/10.4172/2324-9005.1000120
(asked only for male), sexual orientation, homosexual experience in
exchange for drugs, history of STIs, abortion experience (asked for
both gender), morning after pill (asked only to female), and age at the
time of first intercourse.
More than half of the participants 54.3% (n=165) used condoms
in all sexual relations (oral, vaginal, and/or anal), while 27.3% (n=83)
of the participants did not use condoms, and 18.4% (n=56) of the
participants reported irregular or inconsistent use of condoms.
Drug Abuse Screening Test (DAST) 20. The DAST consisted of
20 questions related to drug use within the last year. The questions
pertained specifically to abuse, dependence, withdrawal (signs and
symptoms), social impairment, family relations, legal implications,
medical problems, and previous treatment. The problem severity
was classified on a scale from 0 to 20 and was scored as follows: 0
= no problem; from 1 to 5 = mild; 6 to 10 = moderate; 11 to 15 =
substantial; and 16 to 20 = severe. The severity scale has been used
in several studies, and measures of reliability and validity have been
reported to be satisfactory in all the versions for utilization as a clinical
and or research tool. However, the DAST has not yet been validated
in Brazil or other Portuguese language communities [21].
The last two groups were pooled for analysis. When analyzed
by gender, the percentage of males that always used a condom was
higher (57.4%) than females (40%), p<0.019. The main reasons for
the non-use of condoms by crack cocaine smokers included a steady
partner 40.6% (n=56), decreased sensitivity 31.9% (n=44), and
excessive arousal 9.4% (n=13) did. The other 18.4% (n=25) reported
“other reasons” including the following responses: forgetting to use,
fear of offending the other person asking about condom use, the idea
that the condom is not necessary because another contraception
method is being used, or did not know. The participants included
60.9% (n=184) crack-addicted individuals with substantial and severe
problems related to crack cocaine use according to the DAST. The
individuals used crack for an average of 14.1 years (SD=8.7), CI 95%
[12.9; 15.3], and received an average of 2.9 (SD = 3.5, CI95% = [2.5;
3.4] treatments prior to this hospitalization.
Data Analyses
A descriptive data analysis was initially performed. For
the categorical variables, the absolute and relative frequencies
are presented, and for the numerical variables, the frequency
measurements (mean, minimum, maximum, and standard deviation)
are presented. Statistical analyses include chi-square test or the
Fisher’s exact test for small samples, Student’s t-test for independent
samples and logistic regression. The logistic regression was used to
simultaneously evaluate the effects of the socio-demographic features,
the level of crack-related problems (DAST) and sexual behaviours.
The fitting adequacy the final logistic models was assessed via the
Hosmer and Lemeshow test. The sensitivity and specificity were
calculated from the ROC curve that allowed the definition of a cut-off
in the probabilities of success estimated from the fitted model. For
all the statistical tests, a significance level of 5% was considered. The
statistical analyses were performed using the Statistical Package for
Social Science (SPSS version 20.0) and Stata 12.
Results
The participants consisted of 304 crack cocaine smokers. The
sample included 81.9% (n= 249) male and 18.1% (n=55) female
participants, ranging in age from 32 to 75 years (S=9.8, CI95% [30.9;
33.1]). Most of the participants were: unmarried 71.4% (n=217), 47%
(n=143) reported education up to four years, 20.4% (n=62) illiterate,
55.6% (n=166) non-white, 54.6% (n=166) Catholic, 69% (n=210)
unemployed and 44.7% (n=142) earned a minimum wage of less than
$330 dollars.
In relation to male participants, there were significant relationships
between the use of condoms and marital status (p=0.007), educational
level (p< 0.001), race (p=0.002), religion (p<0.001), employment
status (p<0.001), and salary (p<0.001). For females, condom use
was associated with the educational level (p=0.048), race (p=0.002),
religion (p=0.039) and salary (p=0.045). In males there was no
difference in the mean age (t=0.05; p=0.961) of those using condoms
(mean=31.7 years old, SD=10.3 years) and non-users (mean=31.8
years old, SD=8.2 years). Similarly, there was no difference in the
mean age of females (t=1.44; p=0.156) using condoms (mean=30.7
years old, SD=11 years) and non-users (mean=35 years old, SD=11
years).
The average age at first sexual intercourse was 14.7 years (SD=3.2,
CI95% [14.3: 15.1]). There were no differences in the mean age [t=0.87 (p=0.386)], age at first sexual intercourse [t=-0.16 (p=0.872)],
number of partners in the past 12 months [t=-0.88 (p=0.379)] and
sexual intercourse frequency per week [t=-1.26 (p=0.210)] with
the use or non-use of condoms. In the males, associations were
observed between condom use and sexual activity in the past 12
months (p<0.001), homosexual experience (p=0.001), homosexual
experience in exchange for drugs (p<0.001), presence of STIs in life
(p<0.001), HIV test (p<0.001), abortion history (p<0.001), and sex
with sex worker (p<0.001). In the females, condom use was only
associated with sexual activity in the past 12 months (p<0.001), HIV
test (p=0.011) and abortion experience (p=0.004).
Table 1: Distribution by chemical dependence according to condom use by sex.
Male
Condom Use
Yes
Noa
100.0%
DAST
100.0%
100.0%
No problem
0.8%
1.4%
Low level
29.8%
51.4%
Moderate level
7.7%
7.0%
Odds ratio
CI95%b
Female
Condom Use
Yes
Noa
Odds ratio
CI95%b
-
100.0%
100.0%
100.0%
-
-
0.0%
0.0%
0.0%
-
0.9%
1.00
-
22.2%
50.0%
3.1%
1.00
-
8.5%
0.02
[0.00;0.23]
20.4%
13.6%
25.0%
0.03
[0.00;0.94]
Substantial level
31.0%
18.3%
48.1%
0.01
[0.00;0.11]
35.2%
18.2%
46.9%
0.02
[0.00;0.63]
Severe level
30.6%
21.8%
42.5%
0.01
[0.00;0.13]
22.2%
18.2%
25.0%
0.05
[0.00;0.95]
P
<0.001c (79.25;4)
<0.001d
No = never use condoms or use condoms irregularly
CI95%- confidence interval of 95% for odds ratio
c
Descriptive level of chi-square (test statistic, degrees of freedom)
d
Descriptive level of Fisher's exact test
a
b
Volume 3 • Issue 2 • 1000120
• Page 2 of 5 •
Citation: Diehl A, Vieira DL, Rassool GH, Pillon SC, Laranjeira R (2014) Sexual Behaviours and Condom Use in a Sample of Brazilian Crack Cocaine Smokers.
J Addict Behav Ther Rehabil 3:2.
doi:http://dx.doi.org/10.4172/2324-9005.1000120
As shown in Table 1, an association between condom use and the
DAST (p<0.001) was observed in males.
In the final model for males, the DAST variables, sexual activity in
the past 12 months and the number of partners in the past 12 months
remained significant (Figure 1). The model showed good fit adequacy
according to the Hosmer-Lemeshow test (p=0.964). The probabilities
of condom use (always) in crack cocaine smokers with moderate,
substantial and severe addiction were 95%, 98% and 98% lower,
respectively, than the crack cocaine users with low addiction/without
problem with crack with the other variables controlled. Individuals
who were sexually active in the past 12 months exhibited 85% lower
probability of condom use than individuals who did not have sexual
intercourse in the past 12 months. Furthermore, individuals with
three or more partners in the past year exhibited 3.7 times higher
probability to use a condom (always) compared with individuals with
up to two partners. The probability of the crack cocaine smokers to
always use condoms was estimated using the profile of the significant
variables in the model. Using the ROC curve, a cut-off of 0.479
(47.9%) was obtained in the probability associated with a sensitivity
of 76.2% and specificity of 74.5%. Thus, if all the males with estimated
probability equal or higher than 0.479 (47.9%) are classified as those
who always used condoms, the model will correctly classify 76.2% of
crack cocaine smokers who actually use condoms. Similarly, from the
smokers who did not always use condoms, 74.5% will be correctly
classified as those who did not always use condoms.
For females, due to the small number of cases (N=55), education,
race, religion, salary range, DAST, sexual activity in the past 12
months, HIV test, and abortion experience were included in the
logistic regression model as explanatory variables with significance
at 5% in the univariate analysis (Figure 2). The final model showed a
good fit adequacy (p=0.872). The variables educational level, race and
DAST remained significant in the final model for female. Using the
ROC curve, a cut-off of 0.332 (33.2%) was obtained in the probability
associated with a sensitivity of 90.9% and specificity of 72.7%.
In Figure 3, gender, number of partners and race were significant
for discriminating the reasons for not using condoms among crack
cocaine smokers. Thus, gender was the most important variable.
Females tend to indicate “other reasons” for not using condoms 39.4%;
(n=13), while males more commonly indicate a loss of sensitivity
36.2% (n=38) compared with females 18.2% (n=6). For the females,
no other feature was important to discriminate the reasons for not
using condoms. We found values for this discrimination only for the
variable level of problems with crack cocaine (DAST) (p=0.054). For
men, the number of partners was significant; men with three or more
partners indicated more loss of sensitivity, 47.4% (n=18), while those
with up to two partners indicated the stable partner as the reason,
52.2% (n=35). For the latter group, race was significant because
white males indicated to have more stable partners, 62.2% (n=23),
while non-white males also indicated equally loss of sensitivity and
stable partner, 40% (n=12). As for the individuals with three or more
partners, no other variable was significant.
Discussion
It was observed that gender was the most important variable for
the discrimination of non-use of condoms. In this sample of crack
Figure 1: Confidence interval 95% for the odds ratio for the factors in the
final model – Males.
Figure 2: Confidence interval 95% for the odds ratio for the factors in the
final model – Female.
Volume 3 • Issue 2 • 1000120
Figure 3: Confidence interval 95% for the odds ratio for the factors in the
final model – Males and Females.
• Page 3 of 5 •
Citation: Diehl A, Vieira DL, Rassool GH, Pillon SC, Laranjeira R (2014) Sexual Behaviours and Condom Use in a Sample of Brazilian Crack Cocaine Smokers.
J Addict Behav Ther Rehabil 3:2.
doi:http://dx.doi.org/10.4172/2324-9005.1000120
cocaine smokers, three main reasons were observed for non-use of
condoms: stable partner (40%), loss of sensitivity (31%), and too
aroused to use a condom (9.4%). Females tend to indicate “other
reasons” for not using a condom (39.4%), while males show more
sensitivity loss compared with females (36.2% among males and
18.2% among females). The rationale for not using condoms were
similar between the sample of crack cocaine users and the Brazilian
general population. A population-based study conducted in Brazil
reported the main reason for not using condoms is a stable partner
(82.1% of females and 76.3% of men, p<0.001), followed by reduced
sensitivity (6.6% of females and 12.8% of men) [22].
Other studies regarding condom use in females have shown that
other reasons for not using condoms include knowing the partner
well, a general dislike for condoms, condom-related attitudes
(negative condom attitudes), no condoms available, marital status
(being married vs. other marital status classification), religiosity
(lesser), greater amount of illegal drug use, drug problems (more
drug problems = more negative condom attitudes), and perceiving
no need for condoms [23-26]. Unfortunately, attempts to change the
sexual risk behaviours females crack cocaine smokers have been less
successful than efforts to change the needle risk behaviour of injection
drug users [16,27,28]. For the females in our sample, no other feature
was important to discriminate the reasons for not using condoms.
The small total number of females in this sample (only 55) might
explain this fact, no-use of condoms in a smaller sample (only 33)
may not allow other branches of the decision tree. However, among
the males, the number of sexual partners was a predictor of non-use
of condoms (p = 0.043). Other international studies in crack users
found an association between the number of sexual partners and nonuse of condoms in males that use crack [4,29,30]. The findings of this
study corroborate with international studies [17,30-32] regarding the
associations between non-use of condoms in males. and females.
Some studies have shown that the sexual risk associated with
crack use varies based on the social context and the different settings
in which crack cocaine is used. The vulnerability for risky sexual
practices such as sex exchanges for money or drugs and sexual
victimization is likely higher [9,10,31]. Protective factors for condom
use in this sample include being male, single, illiterate, non-white,
Catholic, unemployed and low income. The variables illiteracy,
low income and unemployment were different from other studies
because we found lower probabilities of condom use in individuals
with these features [15]. However, it is worth noting that this sample
is predominantly comprised by vulnerable individuals from the
standpoint of education, employment and income. Moreover, among
the illiterate of this sample, a high percentage reported no sexual
activity in the past 12 months (98.2%). The lower opportunity for
sexual activity may be interfered as an explanatory factor for the
finding in this sample [33].
This study is limited because the recruitment took place at a
tertiary service; therefore, this sample of crack cocaine smokers may
not be representative of the crack cocaine smokers population and
must be treated as a convenience sample. It can be assumed that only
the most chaotic or chronic patients receive this type of treatment.
This sample bias may therefore limit the external validity of these
findings and generalization. The study was also limited because the
authors did not use scales to assess items such as an individual’s
feelings of confidence in purchasing condoms, properly wearing
condoms and negotiating condom use with a new sexual partner. No
Volume 3 • Issue 2 • 1000120
validated scale, such as the condom attitude scale, the condom use
self-efficacy scale (CUSES), the negative condom beliefs scale, or the
condom self-efficacy scale (CSE) developed for American adolescents,
has been validated in Brazil. A validated scale could have increased
the power of information through measurement of condom use selfefficacy with contextually suitable, valid and reliable instruments due
to the variability of scale across nations with different cultural and
ethnic backgrounds [34-36].
Conclusion
Understanding the condom-use patterns and the reasons for
both males and females to choose whether to use condoms with their
sexual partners (steady or casual) and the overall attitudes toward
condom use is important to the development and implementation of
appropriate interventions of health promotion and harm reduction
that can support the condom use in crack cocaine smokers. Health
education programmes for women would include the use of condoms
and how to negotiate condom use with their partners. There is a need
to adapt interventions that take into account the beliefs, ethnicity,
educational and socio-economic status of women in the different
regions of Brazil. This can be done through the use of cognitive
behavioural therapy such as motivational interviewing. There is also
an urgent need to empower these women to have regular contact with
the primary health care services.
To increase condom use, treatment programmes should consider
gender-specific targeting of particular attitudes toward condom use
in this type of drug abuse population. Brief group interventions,
such as positive choices, educational or motivational interventions,
have been evaluated with some success to increase condom use and
the intention to use condoms and to change condom use attitudes
and beliefs in crack cocaine smokers [37]. In this sample and in the
general population, males and females exhibit different frequencies
and reasons for condom use, which is an important issue for the
development and implementation of gender-targeted, culturally
appropriate interventions that can promote condom use in crack
cocaine smokers. Future studies need to include other involving other
methodologies and samples (multicenter studies for example) to
gather further information about these important issues. The major
strength of this study is that it is one of the few studies developed with
sample of crack cocaine users in Brazil.
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Behav 14: 48-58.
Volume 3 • Issue 2 • 1000120
Author Affiliations
Top
Federal University of São Paulo (UNIFESP), National Institute of Alcohol and
Drugs Policy (INPAD), Brazil
2
Sakina Counselling Institute, Mauritius
3
University of São Paulo (USP), Faculty of Nursing at Ribeirão Preto, Brazil
1
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