Crack Use Sites and HIV Risk in El Salvador
Dickson-Gomez, Julia, Bodnar, Gloria, Guevara, Aradenia, Rodriguez, Karla, Gaborit, Mauricio, Journal of Drug Issues
"The Social Context of Crack Use and Related Sexual Risk in El Salvador" study was designed to increase knowledge of the locations where drugs are consumed in urban San Salvador, the social dynamics within such sites, and their implications for HIV risk and prevention efforts. In-depth interviews with crack smokers reveal several different types of sites where drugs are consumed and risky sex may occur including trances (generally houses where crack is sold and consumed), brothels, motels, drug users' own homes, abandoned buildings, the street, parks, or cantinas. These range from private sites, where site "gatekeepers" strictly control access, to public sites where access is more open. However, even in more public sites there is considerable social interaction, rules regarding site usage, and in some cases gatekeeper control of the site. Social dynamics already normative at drug use sites may support a site-based, peer-led intervention approach.
According to a report by USAID's Bureau of Global Health, the prevalence of HIV in El Salvador is 0.7%, although they estimate the prevalence for vulnerable populations such as commercial sex workers and street children to be considerably higher at 10% and 20%, respectively (USAID Bureau of Global Health, 2004). The primary exposure category is through heterosexual transmission (78.8%), followed by men who have sex with men (13.6%), with injection drug use comprising only 0.9% of the cases (UNAIDS/World Health Organization [WHO], 2002). Along with the increase in HIV infection, the local market for cocaine has greatly expanded in the last decade and crack cocaine is a growing problem in San Salvador's greater metropolitan area in marginal and working class communities (Dickson-Gomez, 2004; Santacruz Giralt, & Concha-Eastman, 2001; United Nations Development Program, 2004). A national survey conducted in 2004 found that 1% of the population aged 12 to 45 living in San Salvador consumed crack in the last month, while a study of nearly 1,000 gang members found that 65.7% had consumed crack in the last month, and 25.8% consumed crack daily (Santacruz Giralt & Concha-Eastman, 2001).
HIV researchers have increasingly called attention to the need to understand the social context in which risky sex and drug use takes place in order to plan more effective HIV prevention interventions (Carlson, 2000; Koester, 1995; Weeks et al., 2001). There is now a considerable body of qualitative and ethnographic research in the United States and other developed countries on the locations where risky sex and drug use takes place, the social dynamics, rules and norms present in these high risk sites (Chitwood et al., 1990; Inciardi, 1993, 1995; Latkin et al., 1994; Page & Llanusa-Cestero, 2006; Page & Salazar Fraile, 2001; Page, Smith, & Kane, 1991; Waiters & Guydish, 1994; Weeks et al., 2001). However, very little research has examined the social context of risky sex and drug use in developing countries.
THE SOCIAL CONTEXT OF CRACK USE
In the United States, crack use has been associated with a number of sexual behaviors that may contribute to the spread of HIV and AIDS (Inciardi, 1993; Ratner, 1993; Ross, Hwang, Leonard, Teng, & Duncan, 1999; Ross, Hwang, Zack, Bull, & Williams, 2002). Many researchers have argued that crack use has contributed to changes in the conditions in which street sex work takes place, including lowering prices for sexual services (Maher, 1997; Miller, 1995), more sex partners (Inciardi, 1989), higher risk sexual practices (Ratner, 1993), and increases in direct "sex for crack" exchanges (Bourgois & Dunlap, 1993; Boyle & Anglin, 1993; Inciardi, 1993; Koester & Schwartz, 1993; Ouellet, Wiebel, Jiminez, & Johnson, 1993; Ratner, 1993). Sex for crack exchanges are reported to be particularly prevalent in crack houses, where the drug is either bought, consumed or both, and often involve extreme degradation of women who can exercise less control than in sex for money exchanges (Bourgois & Dunlap, 1993; Miller, 1995). …