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��ࡱ�>��	������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������	����bjbjW�W�	.�5�5�k�,�������  zzzzz�������8���T�Q*$:::/;�)�)�)�)�)�)�)$o,�!/V�)zCCC�)zz::��).�%�%�%C6z:z:�)�%C�)�%�%8(`(:�����kʇ�(�����y �P(�)*<Q*X(w/##�w/`(w/z`(8CC�%CCCCC�)�)�%CCCQ*CCCC��������������������������������������������������������������������w/CCCCCCCCC  @:	Sexual Behaviours and Condom Use in a Sample of Brazilian Crack Cocaine Smokers 

Alessandra Diehl1 Denise Leite Vieira2 G Hussein Rassool3 Sandra Cristina Pillon4  & Ronaldo Laranjeira5 

1  MSc. Psychiatrist, Federal University of S�o Paulo (UNIFESP),National Institute of Alcohol and Drugs Policy (INPAD),Brazil.
2 PhD. Psychologist, Federal University of S�o Paulo (UNIFESP),National Institute of Alcohol and Drugs Policy (INPAD), Brazil.
3 PhD. Professor & Executive Director, Sakina Counselling Institute, Mauritius.
4 PhD. Professor, University of S�o Paulo (USP). Faculty of Nursing at Ribeir�o Preto, Brazil
5 PhD. Professor,  Federal University of S�o Paulo (UNIFESP),National Institute of Alcohol and Drugs Policy (INPAD),Brazil




Running Title: Sexual Behaviours and Condom Use in Crack Cocaine Users
Correspondence: Alessandra Diehl
Rua Botucatu, 394 - Vila Clementino, 04038-001 - S�o Paulo - SP, Brazil. 
Fax/Telephone: (55 11) 55795643. Email:  HYPERLINK "mailto:alediehl@terra.com.br" alediehl@terra.com.br








Sexual Behaviours and Condom Use in a Sample of Brazilian Crack Cocaine Smokers 




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 about 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

Brazil is currently considered to be the largest global market for crack cocaine in the world. Approximately 1.8 million people reported using crack cocaine during their life, and one million people have used crack in the past year [1]. 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 [2]. Injecting drug users (IDUs) have historically received greater attention in studies of condom use and sexual behaviours in the transmission of sexually transmitted disease (STIs) and HIV [3-4]. IDUs are at greater risk of developing blood-borne viruses than the general population and many engage in shared injections and vulnerable sexual behaviours[ 5-7).

(INPAD, 2012). 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 (Rodrigues et al., 2012). Injecting drug users (IDUs) have historically received greater attention in studies of condom use and sexual behaviours in the transmission of sexually transmitted disease (STIs) and HIV (Khan et al., 2013; Marshall et al., 2009). IDUs are at greater risk of developing blood-borne viruses than the general population and many engage in shared injections and vulnerable sexual behaviours (Brodish et al., 2011; Chikovani et al., 2013; Judd et al., 2005).
Crack cocaine smokers exhibit high levels of risky sexual behaviour [8-10](Brewe et al., 2007; Kang et al., 2005; Pallonen et al., 2009). 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 [8, 11-12](Brewer et al., 2007; MacMaster et al., 2009; Maticka-Tyndale, 2012); who exchange sex for drugs and let the partner decide whether to use a condom [13-14](Nappo et al., 2011; Ober et al., 2011). In a sample of 125 female crack cocaine smokers from impoverished communities in Salvador, Bahia, 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 [15](Nunes et al., 2007). 

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 [12, 14].(Maticka-Tyndale, 2012; Ober et al., 2011). 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 [16-18](Ross et al., 2003; Sanders et al., 2012; Zou et al., 2012). 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 (American Psychiatric Association, 2000). 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 (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. 
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 tools. However, the DAST has not yet been validated in Brazil or other Portuguese language communities (Yudko, Lozhkina, & Fouts, 2007).

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% male (n = 249) and 18.1% (n = 55) female participants, ranging in age from 32 to 75 years (SD = 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.
More than half of the participants (54.3%; n = 165) used condoms in all sexual relations (oral, vaginal, and/or anal), while 27.3% of the participants (n = 83) did not use condoms, and 18.4% of the participants (n = 56) reported irregular or inconsistent use of condoms. 
The last two groups were pooled for analysis. When analyszed 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 184 (60.9%) 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 hospitaliszation. 

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).  
As shown in Table 21, an association between condom use and the DAST (p < 0.001) was observed in males. 

Insert Table 21 here

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.

Insert Figure 1 here

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%.

Insert Figure 2 here

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 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) [19].(Abdo, 2004).

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 [20-23]. (Bungay et al., 2010; Miranda et al., 2011; Norman et al., 2011; Sterk et al., 2004). 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 [15, 24-25]. 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 (Malchy et al.,2011; Montoya, 1998; Nunes et al., 2007). 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 non-use of condoms in males that use crack [3, 26-27]. The findings of this study corroborate with international studies [16, 28-29] 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 [8-9, 28]. 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 [14]. 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 [30].

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 generalisation. 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 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 self-efficacy with contextually suitable, valid and reliable instruments due to the variability of scale across nations with different cultural and ethnic
(Atkinson et al., 2010; Khan et al. 2013; Timpson et al., 2010). The findings of this study corroborate with international studies (Dickson-Gomez et al., 2012; Ross et al., 2003; Sch�nnesson et al., 2008; Timpson et al., 2010) 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 (Brewer et al., 2007; Dickson-Gomez et al., 2012; Kang et al., 2005).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 (Ober et al., 2011). 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 (Zuilkowski & Jukes, 2012).
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 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 self-efficacy with contextually suitable, valid and reliable instruments due to the variability of scale across nations with different cultural and ethnic backgrounds [31-33].
(Barkley & Burns, 2000; Brafford & Beck, 1991; Siegler et al., 2012).

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 that can promote condom use in crack cocaine smokers. 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 [34]. (Williams et al., 2012). 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.
References
1.INPAD. (2012). II Levantamento Nacional de Alcool e Drogas (LENAD) http://inpad.org.br/lenad/cocaina-e-crack/resultados-preliminares/.
2.Rodrigues D. S, Backe, D. S, Freitas  H.M, Zamberlan C, Gelhen M. H,  Colom�, J. S (2012) Knowledge derived from studies on crack: An incursion into Brazilian dissertations and theses. Ciencia & Saude Coletiva 17:1247-1258.
3.Khan M. R, Berger A, Hemberg J, O'Neill  A, Dyer, T. P, Smyrk, K (2013) Non-injection and injection drug use and STI/HIV risk in the United States: The degree to which sexual risk behaviors versus sex with an STI-infected partner account for infection transmission among drug users. AIDS and Behavior 17, 1185-1194.
4.Marshall B. D, Wood E, Zhang, R, Tyndall M. W, Montaner J. S,  Kerr T (2009) Condom use among injection drug users accessing a supervised injecting facility. Sexually Transmitted Infections 85:121-126.
5.Brodish P, Singh K, Rinyuri A, Njeru C, Kingola  N, Mureithi P, Weir, S (2011)  Evidence of high-risk sexual behaviors among injection drug users in the Kenya PLACE study. Drug and Alcohol Dependence 119:138-141.
6.Chikovani I, Goguadz, K, Bozicevic I, Rukhadze N, Gotsadze G. (2013). Determinants of risky sexual behavior among injecting drug users (IDUs) in Georgia. AIDS and Behavior 17: 1906-1913.
7.Judd A, Hickman M, Jones S, McDonald T, Parry J. V, Stimson G. V,  Hall A. J (2005) Incidence of hepatitis C virus and HIV among new injecting drug users in London: Prospective cohort study. British Medical Journal 330: 24-25.
8.Brewer T. H, Zhao W, Metsch L. R, Coltes A,  Zenilman J (2007) High-risk behaviors in women who use crack: Knowledge of HIV sero status and risk behavior. Annals of Epidemiology 17: 533-539.
9.Kang S. Y, Deren S, Andia J, Col�n H. M, Robles R (2005) Egocentric HIV risk networks among Puerto Rican crack users in New York and in Puerto Rico: Impact on sex risk behaviors over time. AIDS Education and Prevention 17:53-67.
10.Pallonen U. E, Timpson S. C, Williams M. L,  Ross M. W (2009) Stages of consistent condom use, partner intimacy, condom use attitude, and self-efficacy in African-American crack cocaine users. Archives of Sexual Behavior 38:149-158.
11.MacMaster S. A, Rasch R. F, Kinzly M. L, Cooper R. L, Adams S. M (2009) Perceptions of sexual risks and injection for HIV among African American women who use crack cocaine in Nashville, Tennessee. Health & Social Work 34: 283-291.
12.Maticka-Tyndale E. (2012) Condoms in sub-Saharan Africa. Sexual Health  9: 59-72. 
13.Nappo S. A , Sanchez  Z, De Oliveira L. G (2011) Crack, AIDS, and women in S�o Paulo, Brazil. Substance Use & Misuse 46:476-485.
14.Ober A. J, Iguchi M. Y, Weiss R. E, Gorbach P. M, HeimerR, Ouellet L. J, Zule W. A (2011) The relative role of perceived partner risks in promoting condom use in a three-city sample of high-risk, low-income women. AIDS and Behavior 15: 1347-1358.
15.Nunes C. L, Andrade T, Galv�o-Castro B, Bastos F. I,  Reingold A (2007) Assessing risk behaviors and prevalence of sexually transmitted and blood-borne infections among female crack cocaine users in Salvador--Bahia, Brazil. Brazilian Journal of Infectious Diseases 11: 561-566.
16.Ross M. M, Timpson S. C, Williams M. L,  Bowen A. M (2003) Situational correlates of condom use in a sample of African-American drug users who are primarily crack cocaine users. AIDS and Behavior 7: 55-60. 
17.Sanders  S. A, Yarber W. L, Kaufman E. L, Crosby R. A, Graham C. A, Milhausen R. R (2012) Condom use errors and problems: A global view. Sexual Health 9: 81-95.
18.Zou H, Xue, H, Wang X, Lu, D (2012) Condom use in China: Prevalence, policies, issues and barriers. Sexual Health 9:27-33.
19.Abdo C. H (2004) Estudo da vida sexual do Brasileiro [Study of the Brazilian's sexual life]. Editora Bregantini, S�o Paulo, Brazil.
20.Bungay V, Johnson J. L, Varcoe C,  Boyd S (2010). Women's health and use of crack cocaine in context: Structural and 'everyday' violence. International Journal on Drug Policy 21: 321-329.
21.Miranda A. E, Figueiredo N. C, McFarland W, Schmidt R, Page K. (2011). Predicting condom use in young women: Demographics, behaviours and knowledge from a population-based sample in Brazil. International Journal of STD and AIDS 22: 590-595.
22.Norman L. R. Garriga C. A, Cintron L (2011) Condom-use patterns among women who live in public housing developments in Ponce, Puerto Rico. Journal of Health Care for the Poor and Underserved 22: 122-145.
23.Sterk C. E, Klein H, Elifson K. W (2004) Predictors of condom-related attitudes among at-risk women. Journal of Women�s Health 13: 676-688.
24.Malchy L. A, Bungay V, Johnson J. L,Buxton, J (2011) Do crack smoking practices,change with the introduction of safer crack kits? Canadian Journal of Public Health 102: 188-192.
25.Montoya I. D (1998) Social network ties, self-efficacy, and condom use among women who use crack cocaine: A pilot study. Substance Use & Misuse 33: 2049-2073.
26.Atkinson J. S, Williams M. L, Timpson S. C,  Schonnesson L. N (2010) Multiple sexual partnerships in a sample of African-American crack smokers. AIDS and Behavior 14: 48-58.
27.Timpson S. C, Williams M. L, Bowen A. M, Atkinson J. S,  Ross, M. W (2010) Sexual activity in HIV-positive African American crack cocaine smokers. Archives of Sexual Behavior 39: 1353-1358.
28.Dickson-Gomez J, McAuliffe T, Rivas de Mendoza L, Glasman L,  Gaborit M (2012) The relationship between community structural characteristics, the context of crack use, and HIV risk behaviors in San Salvador, El Salvador. Substance Use & Misuse 47: 265-277.
29.Sch�nnesson L. N, Atkinson J, Williams M. L, Bowen A, Ross M. W, Timpson S. C. (2008) A cluster analysis of drug use and sexual HIV risks and their correlates in a sample of African-American crack cocaine smokers with HIV infection. Drug and Alcohol Dependence 97: 44-53.
30.Zuilkowski S. S, Jukes M. C (2012) The impact of education on sexual behavior in sub-Saharan Africa: A review of the evidence. AIDS Care 24: 562-576.
31.Barkley T. W,  Burns J. L (2000). Factor analysis of Condom Use Self-Efficacy Scale among multicultural college students. Health Education Research 15: 485�489.
32.Brafford L. J, Beck K. H (1991) Development and validation of a condom self-efficacy scale for college students. Journal of American College Health 39: 219-225.
33.Siegler A. J, Mbwambo J. K, McCarty F. A, DiClemente R. J (2012) Condoms "contain worms" and "cause HIV" in Tanzania: Negative Condom Beliefs Scale development and implications for HIV prevention. Social Science & Medicine 75: 1685-1691.
34.Williams M, Bowen A, Ross M, Timpson S, Pallonen U,  Amos C. (2008). An investigation of a personal norm of condom-use responsibility among African American crack cocaine smokers. AIDS Care 20: 218-227.

References
Abdo, C. H. (2004). Estudo da vida sexual do Brasileiro [Study of the Brazilian's sexual life]. S�o Paulo, Brazil: Editora Bregantini.
American Psychiatric Association. (2000)Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision. Arlington, VA: American Psychiatric Association.
Atkinson, J. S., Williams, M. L., Timpson, S. C., & Schonnesson, L. N. (2010). Multiple sexual partnerships in a sample of African-American crack smokers. AIDS and Behavior, 14, 48-58
Barkley, T. W., & Burns, J. L. (2000). Factor analysis of Condom Use Self-Efficacy Scale among multicultural college students. Health Education Research, 15, 485�489.
Brafford, L. J., & Beck, K. H. (1991). Development and validation of a condom self-efficacy scale for college students. Journal of American College Health, 39, 219-225.
Brewer, T. H., Zhao, W., Metsch, L. R., Coltes, A., & Zenilman, J. (2007). High-risk behaviors in women who use crack: Knowledge of HIV sero status and risk behavior. Annals of Epidemiology, 17, 533-539.
Brewer, T. H., Zhao, W., Metsch, L. R., Coltes, A., & Zenilman, J. (2007). High-risk behaviors in women who use crack: Knowledge of HIV serostatus and risk behavior. Annals of Epidemiology, 17, 533-539.
Brodish, P., Singh, K., Rinyuri, A., Njeru, C., Kingola, N., Mureithi, P., . . . Weir, S. (2011). Evidence of high-risk sexual behaviors among injection drug users in the Kenya PLACE study. Drug and Alcohol Dependence, 119, 138-141.
Bungay, V., Johnson, J. L., Varcoe, C., & Boyd, S. (2010). Women's health and use of crack cocaine in context: Structural and 'everyday' violence. International Journal on Drug Policy, 21, 321-329.
Chikovani, I., Goguadze, K., Bozicevic, I., Rukhadze, N., & Gotsadze, G. (2013). Determinants of risky sexual behavior among injecting drug users (IDUs) in Georgia. AIDS and Behavior, 17, 1906-1913.
Dickson-Gomez, J., McAuliffe, T., Rivas de Mendoza, L., Glasman, L., & Gaborit, M. (2012). The relationship between community structural characteristics, the context of crack use, and HIV risk behaviors in San Salvador, El Salvador. Substance Use & Misuse, 47, 265-277.
INPAD. (2012). II Levantamento Nacional de Alcool e Drogas (LENAD). Retrieved from http://inpad.org.br/lenad/cocaina-e-crack/resultados-preliminares/.
Judd, A., Hickman, M., Jones, S., McDonald, T., Parry, J. V., Stimson, G. V., & Hall, A. J. (2005). Incidence of hepatitis C virus and HIV among new injecting drug users in London: Prospective cohort study. British Medical Journal, 330, 24-25.
Kang, S. Y., Deren, S., Andia, J., Col�n, H. M., & Robles, R. (2005). Egocentric HIV risk networks among Puerto Rican crack users in New York and in Puerto Rico: Impact on sex risk behaviors over time. AIDS Education and Prevention, 17, 53-67. 
Khan, M. R., Berger, A., Hemberg, J., O'Neill, A., Dyer, T. P., & Smyrk, K. (2013). Non-injection and injection drug use and STI/HIV risk in the United States: The degree to which sexual risk behaviors versus sex with an STI-infected partner account for infection transmission among drug users. AIDS and Behavior, 17, 1185-1194.
Marshall, B. D., Wood, E., Zhang, R., Tyndall, M. W., Montaner, J. S., & Kerr, T. (2009). Condom use among injection drug users accessing a supervised injecting facility. Sexually Transmitted Infections, 85, 121-126.
Miranda, A. E., Figueiredo, N. C., McFarland, W., Schmidt, R., & Page, K. (2011). Predicting condom use in young women: Demographics, behaviours and knowledge from a population-based sample in Brazil. International Journal of STD and AIDS, 22, 590-595.
MacMaster, S. A., Rasch, R. F., Kinzly, M. L., Cooper, R. L., & Adams, S. M. (2009). Perceptions of sexual risks and injection for HIV among African American women who use crack cocaine in Nashville, Tennessee. Health & Social Work, 34, 283-291.

Malchy, L. A., Bungay, V., Johnson, J. L., & Buxton, J. (2011). Do crack smoking 
practices,change with the introduction of safer crack kits? Canadian Journal of Public Health, 
102, 188-192.

Maticka-Tyndale, E. (2012). Condoms in sub-Saharan Africa. Sexual Health, 9, 59-72. 

Montoya, I. D. (1998). Social network ties, self-efficacy, and condom use among women who use crack cocaine: A pilot study. Substance Use & Misuse, 33, 2049-2073.

Nappo, S. A., Sanchez, Z., & De Oliveira, L. G. (2011). Crack, AIDS, and women in S�o Paulo, Brazil. Substance Use & Misuse, 46, 476-485.

Norman, L. R., Garriga, C. A., & Cintron, L. (2011). Condom-use patterns among women who live in public housing developments in Ponce, Puerto Rico. Journal of Health Care for the Poor and Underserved, 22, 122-145.

Nunes, C. L., Andrade, T., Galv�o-Castro, B., Bastos, F. I., & Reingold, A. (2007). Assessing risk behaviors and prevalence of sexually transmitted and blood-borne infections among female crack cocaine users in Salvador--Bahia, Brazil. Brazilian Journal of Infectious Diseases, 11, 561-566.
Ober, A. J., Iguchi, M. Y., Weiss, R. E., Gorbach, P. M., Heimer, R., Ouellet, L. J., . . . Zule, W. A. (2011). The relative role of perceived partner risks in promoting condom use in a three-city sample of high-risk, low-income women. AIDS and Behavior, 15, 1347-1358.
Pallonen, U. E., Timpson, S. C., Williams, M. L., & Ross, M. W. (2009). Stages of consistent condom use, partner intimacy, condom use attitude, and self-efficacy in African-American crack cocaine users. Archives of Sexual Behavior, 38, 149-158.
Rodrigues, D. S., Backes, D. S., Freitas, H. M., Zamberlan, C., Gelhen, M. H., & Colom�, J. S. (2012). Knowledge derived from studies on crack: An incursion into Brazilian dissertations and theses. Ciencia & Saude Coletiva, 17, 1247-1258.
Ross, M. W., Timpson, S. C., Williams, M. L., & Bowen, A. M. (2003). Situational correlates of condom use in a sample of African-American drug users who are primarily crack cocaine users. AIDS and Behavior, 7, 55-60. 
Sanders, S. A., Yarber, W. L., Kaufman, E. L., Crosby, R. A., Graham, C. A., & Milhausen, R. R. (2012). Condom use errors and problems: A global view. Sexual Health, 9, 81-95.
Sch�nnesson, L. N., Atkinson, J., Williams, M. L., Bowen, A., Ross, M. W., & Timpson, S. C. (2008). A cluster analysis of drug use and sexual HIV risks and their correlates in a sample of African-American crack cocaine smokers with HIV infection. Drug and Alcohol Dependence, 97, 44-53.
Siegler, A. J., Mbwambo, J. K., McCarty, F. A., & DiClemente, R. J. (2012). Condoms "contain worms" and "cause HIV" in Tanzania: Negative Condom Beliefs Scale development and implications for HIV prevention. Social Science & Medicine, 75, 1685-1691.
Sterk, C. E., Klein, H., & Elifson, K. W. (2004). Predictors of condom-related attitudes among at-risk women. Journal of Women�s Health, 13, 676-688.
Timpson, S. C., Williams, M. L., Bowen, A. M., Atkinson, J. S., & Ross, M. W. (2010). Sexual activity in HIV-positive African American crack cocaine smokers. Archives of Sexual Behavior, 39, 1353-1358.
Williams, M., Bowen, A., Ross, M., Timpson, S., Pallonen, U., & Amos, C. (2008). An investigation of a personal norm of condom-use responsibility among African American crack cocaine smokers. AIDS Care, 20, 218-227. 
Zou, H., Xue, H., Wang, X., & Lu, D. (2012). Condom use in China: Prevalence, policies, issues and barriers. Sexual Health, 9, 27-33.
Zuilkowski, S. S., & Jukes, M. C. (2012). The impact of education on sexual behavior in sub-Saharan Africa: A review of the evidence. AIDS Care, 24, 562-576.








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