Correlates of sex trading among male non-injecting drug users in Myanmar: a cross-sectional study
© The Author(s). 2016
Received: 13 September 2016
Accepted: 26 November 2016
Published: 5 December 2016
Sex trading is a recognized risk factor for human immune deficiency virus infection and other sexually transmitted infections among non-injecting drug users (NIDUs). However, very little research has addressed the factors associated with sex trading among male NIDUs in Myanmar.
A cross-sectional study was conducted from January to February 2010 using the respondent-driven sampling method. In total, 210 NIDUs aged between 18 and 49 years, with no history of injecting drug use, and who used non-injected illicit drugs in the last 6 months were recruited. Face-to-face interviews were conducted using a structured questionnaire to collect information on participants’ sexual and drug use behaviors. Binary and multivariate logistic regressions were applied to analyze the resulting data.
Of 210 NIDUs, 84 (40%) reported involvement in the sex trade during the last 3 months. In the adjusted model, factors associated with sex trade involvement included homosexual preference (adjusted odds ratio [AOR] 4.90; 95% confidence interval [CI] 1.61–14.95), having more than two partners (AOR = 3.88; 95% CI 1.55–9.72), had a regular job (AOR = 5.10; 95% CI 1.65–15.72), use of stimulant drugs rather than opiate (AOR = 2.38; 95% CI 1.10–5.15), and who used drugs more than twice per day.
More than one third of NIDUs were involved in sex trading. This study suggested that further comprehensive intervention programs that aim to reduce risk factors of trading sex among NIDUs may consider including NIDUs who used stimulant drugs, had regular/full-time jobs, used drugs more than twice per day, and had homosexual preferences.
KeywordsExchange sex Sex trading Drug users Myanmar
Sex trading, for money or drugs, has emerged as a significant public health concern due to a wide range of negative health impacts . Among these, sexually transmitted infections (STIs), including HIV, are one of the recognized risk factors among drug users . In addition, the confounding effects of drug use on psychological distress may contribute to correlations between sex trading and psychological status such as depression, suicide attempts, and social and physical victimization among drug-using populations [1, 3].
The risk of STIs/HIV infection may still be present among non-injecting drug users (NIDUs) through high-risk sexual behaviors even though they do not inject drug intravenously [4, 5]. For example, in theUnited States of America, HIV prevalence among injecting drug users (IDUs) is nearly identical to that among NIDUs due to high-risk sexual behaviors . Many studies reported that sex trading was associated with non or inconsistent use of condoms [7–10] homelessness, unemployment, less education, drug use, and heterosexual (bisexual) behavior . In addition, sex trading is associated with higher rates of adult sexual victimization, experience of violence, and previous history of being sexually abused in childhood .
Myanmar stands as the second largest illicit opium producer in Asia, and the drug-using population may be a key population at risk . The United Nations Office on Drugs and Crime estimated 300,000 drug users in 2008. In Myanmar, approximately 212,000 people were living with HIV in 2014. The HIV epidemic largely effects IDUs, men who had sex with men, and female sex workers . HIV prevalence among IDUs was 23.1%, while adult prevalence was 0.54% in 2014 . However, HIV prevalence among NIDUs is unavailable.
Researchers and policy makers have been paying more attention to IDUs due to their risky injecting behaviors compared to NIDUs [6, 15, 16]. In addition, while several researchers are giving attention to sex trading among male IDUs [11, 17], only a paucity of research addresses factors associated with sex trading among male NIDUs, especially in the developing country settings. This study aims to identify the risk factors of sex trading among male NIDUs in Lashio, Myanmar. The findings of this study may help in fine-tuning suitable national strategies in Myanmar and in Southeast Asia in general to find possible solutions for the health problems as consequences of sex trading.
Study design and participants
The cross-sectional study was conducted from January to February 2010 in Lashio city, Northern Shan State. In total, 210 male NIDUs were recruited using a respondent-driven sampling (RDS) method. The inclusion criteria of this study were as follows: (1) aged 18 years or older, (2) with no history of injecting drug use, (3) had used illicit non-injecting drugs in the previous 6 months, (4) not suffering from a serious drug dependency, and (5) able to speak the Myanmar language.
Participants were recruited using an RDS method that included coupon and dual incentives system [5, 18]. The details of the sampling procedure are presented elsewhere . The first respondent was recruited from a local drop-in center as a seed, and that participant was requested to introduce three drug users through a coupon system. All the participants were requested to recruit their friends/partners within the 14 days before the coupon expiry date. For each interview, participants received 2000 Kyats (US$ 2.5) and an information, education, and communication pack that included two condoms with gel packs as a primary incentive. They were eligible to receive the secondary incentives of 500 kyats (0.5$) only after the NIDUs whom they recruited participated in the study.
Measures and data collection
The data was collected using a standardized, precoded questionnaire adapted from several different studies that had been implemented in Myanmar. Sexual behaviors questions were adapted from the Behavioral Surveillance Survey (BSS) Questionnaire of the Ministry of Health, Myanmar and the sociodemographic characteristics, drug use behavior, and health services utilization questions were adapted from the Rapid Assessment and Response on Drug Use and from the HIV Survey of the Asian Harm Reduction Network, Myanmar [19, 20]. The questionnaire was translated from English to the Myanmar language and was pretested among a sample of NIDUs residing outside the study sites in November, 2009 by the researchers. Back-translation of the instrument from the Myanmar language to English was done before and after the pretest to ensure semantic equivalence via a pilot study for assessing content validity, appropriateness, and question comprehensibility. The questionnaire was then revised as necessary. Training was given to the data collectors for two days on how to conduct the interview, content of the questionnaire, data quality, and ways to approach respondents .
The dependent variable was ever-traded sex for money or drugs in the past 3 months. Sex trading was defined as a participant having exchanged sex for money or drugs as measured by the following question: “In the past three month, did you trade/exchange sex for money or drugs (i.e. received money or drugs through sex-trading)?” . The response of the above question was dichotomized as ever-traded sex (1 = yes) versus never traded sex (0 = no, do not know, and no response). The independent variables included sociodemographic characteristics such as age, ethnicity, marital status, education, employment status, and living status; drug use-related variables such as the most used drug type, history of poly drug use, frequency of drug use, and age; sexual behaviors related characteristics such as age of sexual initiation, sexual orientation, number of sexual partner, and consistent condom use; and HIV testing behaviors, and health service utilization related characteristics such as ever tested HIV and STI/HIV diagnosis [19, 22]. The interview was conducted where NIDU participants felt comfortable discussing this issue, such as a local drop-in center, shooting galleries, or the participant’s home. Each interview took 30 to 45 min.
Data were double entered and cross-checked using Microsoft Excel, and analyzed using the Statistical Package for the Social Sciences version 18 (SPSS Inc., Chicago, IL, USA). The descriptive statistics were calculated for the sociodemographic, drug use, and sexual behavior characteristics of study participants. In all the analyses, the level of significance was set at P < 0.05 (two-tailed). Logistic regression models were fitted to the data to model the crude associations between the background characteristics of the participants and the involvement in sex trading. Finally, all the covariates were simultaneously entered into the stepwise regression analysis to see the most significant variables.
This study was approved by the Research Ethics Committee of the Graduate School of Medicine, the University of Tokyo, Japan and the Institutional Ethical Review Committee, Department of Medical Research (Lower Myanmar), Ministry of Health, Yangon, Myanmar. The objectives of the study were made clear to the respondents before their voluntary participation, and individual written informed consent was obtained from all the participants. Each participant was allowed to withdraw from the study at any time. Confidentiality of the entire data set was maintained at all stages of the data collection and analyses.
Sociodemographic characteristics of participants (N = 210)
Number of cases (N)
Primary/no formal education
High school or above
Correlates of sex trading: crude analysis
Bivariate analysis for correlates of sex trading among non-injecting drug users
Primary/no formal education
High school or above
Most used drug type in the past 3 months
Had history of poly drug use
Frequency of drug use per day
Age of sexual initiation
Had used drugs before or during sex in the past 3 months
Number of sexual partner in the past 3 months
Had new casual partner in the last 1 month
Consistent condom use in the past 3 months
Ever test HIV
Ever received drug treatment
Diagnosed with an STI/HIV in the past 3 months
Ever been in prison or jail
Perceived HIV risk
Ever registered as a drug user
Significantly higher odds ratio of trading sex was observed among participants who had homosexual preferences (UOR 11.38; 95% CI 5.16–25.08) or bisexual preferences (UOR 3.65; 95% CI 1.58–8.45; Table 2). Participants who had more than two partners (UOR 4.96; 95% CI 2.45–10.03) in the past 3 months were more likely to be involved in sex trading. NIDUs, who reported that they had casual partners in the last 1 month were 5.65 times (95% CI 2.51–12.74) times more likely to report having trade sex. In addition, a significant association was observed between sex trading and those who had been diagnosed with a STIs/HIV in the past 6 months (UOR 4.71; 95% CI 2.53–8.77; Table 2).
Correlates of sex trading: multivariate analysis
Multivariate analysis for correlates of sex trading among non-injecting drug users
Most used drug type in the past 3 months
Frequency of drug use per day
Number of sexual partner in the past 3 months
Had used drugs before or during sex in the past 3 months
This is the first study of the relationship between sex trading and associated risk factors among NIDUs in Myanmar. Findings from this study indicate that 40% of the NIDUs engaged in sex trading within the last 3 months. This extremely high prevalence rate confirms that sex trading is an alarmingly commonplace in this impoverished Southeast Asian nation that can potentially place NIDUs at high risk for HIV and other sexually transmitted diseases. The findings of this study document that the higher prevalence of sex trading among NIDUs is similar to the risk level of injection drug users carried out in different developing and developed nations [11, 23–25].
Our findings indicate that stimulant drug use is associated with involvement in sex trading among our sample. This is in line with previous observations that stimulant users often engage in sex trading and high-risk sexual behaviors with multiple sex partners [26–28]. Evidence also shows that some drug users traded sex for drugs, rather than money, to suppress the effects of drug withdrawal [27, 29, 30]. Among the NIDU population, stimulant drugs are believed to be a key contributor of engagement in high-risk sexual behavior [31–33]. These findings, therefore, suggest that preventive interventions addressing sex trading among NIDUs must target stimulant drug users.
Having multiple partners over a short period of time is believed to be a major behavioral factor of STIs . Our findings revealed that participants who had more than two partners in the past 3 months were associated with sex trading. This finding is consistent with previous research, which showed that having multiple sexual partners was associated with increased high-risk sexual behaviors and may increase the risk of HIV and other STIs [35–37]. Another new important finding is that NIDUs whose frequency of drug use was higher (more than twice per day) were more likely to be involved in sex trading. This result is expected because as the frequency of drug use increases so does the likelihood of selling sex to procure drugs.
It has been shown that men who have sex with men were more likely to report a history of trading sex for money or drugs than were heterosexual men . The present results also support the hypothesis indicating that NIDUs with homosexual preferences were more likely to report involvement in sex trading. Heavy substance use is highly prevalent in this community  and, along with poverty and economic needs (“survival sex”), it may be driving much of the ongoing HIV risk behaviors through the exchange of sex for money or drugs . Moreover, an additional analysis was run in this study to examine this hypothesis, and we found that NIDUs with homosexual preferences have higher frequency of drug use (more than twice per day).
This study also shows that NIDUs who used drugs before and during sex in the past 3 months were positively associated with sex trading. This result is in accordance with the previous findings suggesting that using drugs and alcohol before or during sex leads an individual to engage in high-risk sexual behaviors [41–43].
Contrary to the previous studies, our findings demonstrated that sex trading was associated with having a regular income to live on or having a full-time job at the time of survey among male NIDUs in this study. Previous studies revealed that sex trading was associated with unemployment  and homelessness . This may be explained by the fact that regular job holders may sometimes engage in sex trading for stimulant drugs even if they have a full-time job due to illicit drug accessibility, rather than money.
Some limitations should be considered when interpreting our findings. First, the data were based on the participants’ self-report. Regarding questions related to sexual behaviors, there is a possibility of under-reporting and social desirability bias related to the use of the face-to-face interviewing technique. However, in order to minimize this problem, peers of NIDUs were hired as interviewers to make participants feel more comfortable in reporting the truth. Also, confidentiality of the participants was carefully maintained throughout, with RDS identification codes used in place of the participants’ names. Second, there is a possibility of recall bias because participants were asked to report their behaviors in the past 3 months or more. However, to minimize the recall bias, we inquired about details of participants’ sexual behaviors and used validated and reliable instruments to collect data.
Finally, the current analyses are cross-sectional, and thus do not allow us to assess temporal relationships between variables or ascertainment of causal sequences. Despite such limitations, our findings have important implications with regard to designing interventions to reduce sex trade among the NIDUs in Myanmar and comparable settings. The conclusions drawn may also be useful for policy makers to refine and develop future sexual risk reduction programs for the NIDUs in Myanmar.
In conclusion, the NIDUs in Myanmar engaged in trade sex at an elevated rate. That may be one of the reasons behind the higher prevalence of STIs/HIV infection in these populations. Our study recommends an effective comprehensive intervention to reduce risk factors of sex trade among the NIDUs, particularly focusing on NIDUs who used stimulant drugs, who used drugs heavily, had regular jobs, had homosexual preferences, and having multiple types of partners. Developing strategies that include the above interventions may play a crucial role in limiting the spread of HIV among NIDUs and their partners. Since these behaviors have major implications for HIV acquisition and public health, prevention efforts and targeted provision of addiction treatment to this population should be expanded.
Adjusted odds ratio
Human immune deficiency virus
Injecting drug users
Non-injecting drug users
Sexually transmitted infections
Unadjusted odds ratio.
The authors would like to thank all the participants who voluntarily participated in this study. We also would like to thank Dr. Yin Thet Nu Oo and Dr. Lin Aung Thu for their support and contribution.
Availability of data and materials
The datasets analyzed during the current study are available from the corresponding author on reasonable request.
YMS and TNS participated in the design of the study, conducted the statistical analyses, and drafted the article. KCP and WKM participated in the analysis and interpreted the results. YMS, TNS, and WHH oversaw the implementation of study. All authors contributed to the writing of the manuscript and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
This study was approved by the Research Ethics Committee of the Graduate School of Medicine, the University of Tokyo, Japan (Ref. no: 2801/2009) and the Institutional Ethical Review Committee Department of Medical Research (Lower Myanmar), Ministry of Health, Yangon, Myanmar (Letter no: 5/Ethics, 2010). The objectives of the study were made clear to respondents before their voluntary participation and individual written informed consent was obtained from all the participants.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Semple SJ, Strathdee SA, Zians J, Patterson TL. Social and behavioral characteristics of HIV-positive MSM who trade sex for methamphetamine. Am J Drug Alcohol Abuse. 2010;36(6):325–31.View ArticlePubMedPubMed CentralGoogle Scholar
- Rudolph AE, Linton S, Dyer TP, Latkin C. Individual, network, and neighborhood correlates of exchange sex among female non-injection drug users in Baltimore, MD (2005-2007). AIDS Behav. 2013;17(2):598–611.View ArticlePubMedPubMed CentralGoogle Scholar
- El-Bassel N, Simoni JM, Cooper DK, Gilbert L, Schilling RF. Sex trading and psychological distress among women on methadone. Psychol Addict Behav. 2001;15(3):177–84.View ArticlePubMedGoogle Scholar
- Neaigus A, Gyarmathy VA, Zhao M, Miller M, Friedman SR, Des Jarlais DC. Sexual and other noninjection risks for HBV and HCV seroconversions among noninjecting heroin users. J Infect Dis. 2007;195(7):1052–61.View ArticlePubMedGoogle Scholar
- Saw YM, Poudel KC, Kham NP, Chan N, Cope JE, Wai KM, Tun S, Saw TN. Assessment of HIV testing among young methamphetamine users in Muse, Northern Shan State, Myanmar. BMC Public Health. 2014;14:735.View ArticlePubMedPubMed CentralGoogle Scholar
- Strathdee SA, Stockman JK. Epidemiology of HIV among injecting and non-injecting drug users: current trends and implications for interventions. Curr HIV/AIDS Rep. 2010;7(2):99–106.View ArticlePubMedPubMed CentralGoogle Scholar
- Semple SJ, Strathdee SA, Zians J, Patterson TL. Correlates of trading sex for methamphetamine in a sample of HIV-negative heterosexual methamphetamine users. J Psychoactive Drugs. 2011;43(2):79–88.View ArticlePubMedPubMed CentralGoogle Scholar
- Nerlander LM, Hess KL, Sionean C, Rose CE, Thorson A, Broz D, Paz-Bailey G. Exchange Sex and HIV Infection Among Men Who Have Sex with Men: 20 US Cities, 2011. AIDS Behav. 2016;1–2.
- Baral SD, Friedman MR, Geibel S, Rebe K, Bozhinov B, Diouf D, Sabin K, Holland CE, Chan R, Caceres CF. Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission. Lancet. 2015;385(9964):260–73.View ArticlePubMedGoogle Scholar
- Weber AE, Craib KJ, Chan K, Martindale S, Miller ML, Schechter MT, Hogg RS. Sex trade involvement and rates of human immunodeficiency virus positivity among young gay and bisexual men. Int J Epidemiol. 2001;30(6):1449–54. discussion 1455-1446.View ArticlePubMedGoogle Scholar
- Newman PA, Rhodes F, Weiss RE. Correlates of sex trading among drug-using men who have sex with men. Am J Public Health. 2004;94(11):1998–2003.View ArticlePubMedPubMed CentralGoogle Scholar
- Reid G, Costigan G. Revisiting ‘The Hidden Epidemic’: A Situation Assessment of Drug Use in Asia in the context of HIV/AIDS. The Centre for Harm Reduction. Australia: The Burnet Institute; 2002.Google Scholar
- Saw YM, Win KL, Shiao LW, Thandar MM, Amiya RM, Shibanuma A, Tun S, Jimba M. Taking stock of Myanmar's progress toward the health-related Millennium Development Goals: current roadblocks, paths ahead. Int J Equity Health. 2013;12:78.View ArticlePubMedPubMed CentralGoogle Scholar
- National AIDS Programme. Global AIDS Response Progress Report Myanmar. Myanmar: Ministry of Health; 2015.Google Scholar
- Bacon O, Lum P, Hahn J, Evans J, Davidson P, Moss A, Page-Shafer K. Commercial sex work and risk of HIV infection among young drug-injecting men who have sex with men in San Francisco. Sex Transm Dis. 2006;33(4):228–34.View ArticlePubMedGoogle Scholar
- Dutta A, Wirtz AL, Baral S, Beyrer C, Cleghorn FR. Key harm reduction interventions and their impact on the reduction of risky behavior and HIV incidence among people who inject drugs in low-income and middle-income countries. Curr Opin HIV AIDS. 2012;7(4):362–8.View ArticlePubMedGoogle Scholar
- Kuyper LM, Lampinen TM, Li K, Spittal PM, Hogg RS, Schechter MT, Wood E. Factors associated with sex trade involvement among male participants in a prospective study of injection drug users. Sex Transm Infect. 2004;80(6):531–5.View ArticlePubMedPubMed CentralGoogle Scholar
- Johnston LG, Sabin K, Mai TH, Pham TH. Assessment of respondent driven sampling for recruiting female sex workers in two Vietnamese cities: reaching the unseen sex worker. J Urban Health. 2006;83(6 Suppl):i16–28.View ArticlePubMedGoogle Scholar
- Saw YM, Yasuoka J, Saw TN, Poudel KC, Tun S, Jimba M. What are the factors associated with HIV testing among male injecting and non-injecting drug users in Lashio, Myanmar: a cross-sectional study. BMJ Open. 2013;3(6):e002747.
- De Maere W, Singh S, Tun T, Aung KM, Kham NPE, Htun HL, Khine W, Saw YM. Rapid assessment and action research on drug use and HIV in Lashio, Northern Shan State, Myanmar. In. Myanmar: Asian Harm Reduction Network Myanmar (AHRN-Myanmar); 2006.
- Absalon J, Fuller CM, Ompad DC, Blaney S, Koblin B, Galea S, Vlahov D. Gender differences in sexual behaviors, sexual partnerships, and HIV among drug users in New York City. AIDS Behav. 2006;10(6):707–15.View ArticlePubMedGoogle Scholar
- National AIDS Programme. Behavioral Surveillance Survey among Injecting Drug Users and Female Sex Workers. Myanmar: Ministry of Health; 2008.Google Scholar
- Werb D, Hayashi K, Fairbairn N, Kaplan K, Suwannawong P, Lai C, Kerr T. Drug use patterns among Thai illicit drug injectors amidst increased police presence. Subst Abuse Treat Prev Policy. 2009;4:16.View ArticlePubMedPubMed CentralGoogle Scholar
- Benotsch EG, Somlai AM, Pinkerton SD, Kelly JA, Ostrovski D, Gore-Felton C, Kozlov AP. Drug use and sexual risk behaviours among female Russian IDUs who exchange sex for money or drugs. Int J STD AIDS. 2004;15(5):343–7.View ArticlePubMedGoogle Scholar
- Milloy MJ, Fairbairn N, Hayashi K, Suwannawong P, Kaplan K, Wood E, Kerr T. Overdose experiences among injection drug users in Bangkok, Thailand. Harm Reduct J. 2010;7:9.View ArticlePubMedPubMed CentralGoogle Scholar
- Ober A, Shoptaw S, Wang PC, Gorbach P, Weiss RE. Factors associated with event-level stimulant use during sex in a sample of older, low-income men who have sex with men in Los Angeles. Drug Alcohol Depend. 2009;102(1-3):123–9.View ArticlePubMedPubMed CentralGoogle Scholar
- Edlin BR, Irwin KL, Faruque S, McCoy CB, Word C, Serrano Y, Inciardi JA, Bowser BP, Schilling RF, Holmberg SD. Intersecting epidemics–crack cocaine use and HIV infection among inner-city young adults. Multicenter Crack Cocaine and HIV Infection Study Team. N Engl J Med. 1994;331(21):1422–7.View ArticlePubMedGoogle Scholar
- Watt MH, Kimani SM, Skinner D, Meade CS. “Nothing Is Free”: a qualitative study of sex trading among methamphetamine users in Cape Town, South Africa. Arch Sex Behav. 2016;45(4):923–33.View ArticlePubMedGoogle Scholar
- Inciardi JA. Crack, crack house sex, and HIV risk. Arch Sex Behav. 1995;24(3):249–69.View ArticlePubMedGoogle Scholar
- de Souza CT, Diaz T, Sutmoller F, Bastos FI. The association of socioeconomic status and use of crack/cocaine with unprotected anal sex in a cohort of men who have sex with men in Rio de Janeiro, Brazil. J Acquir Immune Defic Syndr. 2002;29(1):95–100.View ArticlePubMedGoogle Scholar
- Degenhardt L, Mathers B, Guarinieri M, Panda S, Phillips B, Strathdee SA, Tyndall M, Wiessing L, Wodak A, Howard J, et al. Meth/amphetamine use and associated HIV. Implications for global policy and public health. Int J Drug Policy. 2010;21(5):347–58.View ArticlePubMedGoogle Scholar
- Lau JT, Tsui HY, Zhang Y, Cheng F, Zhang L, Zhang J, Wang N. Comparing HIV-related syringe-sharing behaviors among female IDU engaging versus not engaging in commercial sex. Drug Alcohol Depend. 2008;97(1-2):54–63.View ArticlePubMedGoogle Scholar
- Hacker MA, Malta M, Enriquez M, Bastos FI. Human immunodeficiency virus, AIDS, and drug consumption in South America and the Caribbean: epidemiological evidence and initiatives to curb the epidemic. Rev Panam Salud Publica. 2005;18(4-5):303–13.View ArticlePubMedGoogle Scholar
- Finer LB, Darroch JE, Singh S. Sexual partnership patterns as a behavioral risk factor for sexually transmitted diseases. Fam Plann Perspect. 1999;31(5):228–36.View ArticlePubMedGoogle Scholar
- Kral AH, Lorvick J, Ciccarone D, Wenger L, Gee L, Martinez A, Edlin BR. HIV prevalence and risk behaviors among men who have sex with men and inject drugs in San Francisco. J Urban Health. 2005;82(1 Suppl 1):i43–50.View ArticlePubMedPubMed CentralGoogle Scholar
- Miguez-Burbano MJ, Jackson Jr J. Alcohol and public health. Lancet. 2005;365(9468):1386–7.View ArticlePubMedGoogle Scholar
- Avants SK, Warburton LA, Hawkins KA, Margolin A. Continuation of high-risk behavior by HIV-positive drug users. Treatment implications. J Subst Abus Treat. 2000;19(1):15–22.View ArticleGoogle Scholar
- McGowan JP, Shah SS, Ganea CE, Blum S, Ernst JA, Irwin KL, Olivo N, Weidle PJ. Risk behavior for transmission of human immunodeficiency virus (HIV) among HIV-seropositive individuals in an urban setting. Clin Infect Dis. 2004;38(1):122–7.View ArticlePubMedGoogle Scholar
- Kalichman SC. Psychological and social correlates of high-risk sexual behaviour among men and women living with HIV/AIDS. AIDS Care. 1999;11(4):415–27.View ArticlePubMedGoogle Scholar
- Kalichman SC, Greenberg J, Abel GG. HIV-seropositive men who engage in high-risk sexual behaviour: psychological characteristics and implications for prevention. AIDS Care. 1997;9(4):441–50.View ArticlePubMedGoogle Scholar
- Stall R, McKusick L, Wiley J, Coates TJ, Ostrow DG. Alcohol and drug use during sexual activity and compliance with safe sex guidelines for AIDS: the AIDS Behavioral Research Project. Health Educ Q. 1986;13(4):359–71.View ArticlePubMedGoogle Scholar
- Calsyn DA, Cousins SJ, Hatch-Maillette MA, Forcehimes A, Mandler R, Doyle SR, Woody G. Sex under the influence of drugs or alcohol: common for men in substance abuse treatment and associated with high-risk sexual behavior. Am J Addict. 2010;19(2):119–27.View ArticlePubMedPubMed CentralGoogle Scholar
- Galvez-Buccollini JA, DeLea S, Herrera PM, Gilman RH, Paz-Soldan V. Sexual behavior and drug consumption among young adults in a shantytown in Lima, Peru. BMC Public Health. 2009;9:23.View ArticlePubMedPubMed CentralGoogle Scholar