Sexual risk behaviours of Puerto Rican drug users in East Harlem New York and Bayamon, Puerto Rico
ABSTRACT Puerto Rican drug users both in New York and Puerto Rico have disproportionately high rates of HIV/AIDS. This paper derives findings from the ARIBBA Project—a dual site study of HIV risk behaviour determinants among Puerto Rican injection drug users and crack smokers, conducted in East Harlem, NY and Bayamón, PR. Qualitative data collected in focus groups, interviews and observations revealed significant diVerences in sexual risk behaviours, perceptions of risks and cultural/behavioural norms between the two locations, which were supported by the results of a survey of 1200 drug users. Recommendations are made for enhancing HIV risk reduction eVorts in both communities.
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ABSTRACT: Reducing sex risk behaviors among high-risk injection drug users (IDUs) and crack smokers is a continuing challenge for HIV prevention. Based on a longitudinal study of sexually active Puerto Rican IDUs and crack smokers in New York (n = 573) and Puerto Rico (n = 264), baseline predictors of changes in sex risk (number of unprotected sex acts) at 6- and 36-month follow-up interviews were examined. In New York, predictors of higher sex risk were being younger, having primary partners, having more other sex partners, never exchanging sex, having lower self-efficacy for reducing sex risk behaviors and being HIV-negative, and these predictors were significant at both postbaseline periods. In Puerto Rico, short-term predictors included being male, having primary partners, never exchanging sex, lower sex risk norms and lower self-efficacy. However, only having primary partners was significant in longer-term behaviors. Results indicated the need for enhancing self-efficacy and for developing risk reduction strategies related to community differences.AIDS Education and Prevention 09/2008; 20(4):325-37. · 1.59 Impact Factor
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ABSTRACT: Puerto Rican drug users recruited in NY who previously used drugs in Puerto Rico (PR) have been found to have higher HIV injection and sex-related risk behaviors than those who had not used in PR. This study examined predictors of risk among migrant Puerto Rican drug users. (For the purpose of this paper, the term "migrant" was used to designate Puerto Rican drug users who had used drugs in Puerto Rico and were recruited in New York or New Jersey). A total of 290 drug users who had previously used drugs in PR were recruited in NY and New Jersey and interviewed regarding drug use history and HIV risk behaviors. Participants engaged in high risk behaviors, e.g., 39% shared injection paraphernalia and 62% reported unprotected sex. Multivariate analyses found that predictors of injection-related risk included being born in PR and purchasing drugs jointly with other drug users; predictors of sex-related risk included younger age and homelessness. Addressing risk reduction among those drug users who were born in Puerto Rico and are younger or homeless was indicated, and efforts to reach those at highest risk through NEPs was recommended.Journal of Immigrant and Minority Health 01/2009; 12(2):179-86. · 1.16 Impact Factor
culture, health & sexuality, 2003, vol. 5, no. 1, 19–35
Sexual risk behaviours of Puerto Rican drug users in East
Harlem New York and Bayamo ´n, Puerto Rico
DENISE OLIVER-VELEZ, SHERRY DEREN, ANN
FINLINSON, MICHELE SHEDLIN, RAFAELA R. ROBLES,
JONNY ANDIA, HECTOR M. COLO´N and SUNG-YEON KANG
Puerto Rican drug users both in New York and Puerto Rico have disproportionately high
rates of HIV/AIDS. This paper derives findings from the ARIBBA Project—a dual site
study of HIV risk behaviour determinants among Puerto Rican injection drug users and
crack smokers, conducted in East Harlem, NY and Bayamo ´n, PR. Qualitative data collected
in focus groups, interviews and observations revealed significant diVerences in sexual risk
behaviours, perceptions of risks and cultural/behavioural norms between the two locations,
which were supported by the results of a survey of 1200 drug users. Recommendations are
made for enhancing HIV risk reduction eVorts in both communities.
A Puerto Rican injection drug user (IDU) interviewed in East Harlem
stated he ‘never shares his works, always uses sterile syringes, uses the
Needle Exchange Programme, and injects alone’. He exhibited a high
degree of awareness about HIV-related injection risks. But when queried
about his sexual behaviours and condom use he replied, ‘I only have sex
with girls who look clean, you know, nice girls’. An IDU in Puerto Rico,
who reported injecting in shooting galleries, when queried about condom
use with his female sex-partner, stated, ‘ella es una mujer decente y yo pense
que no habia necesidad’ (she is a decent woman and I think that there is no
necessity). A crack-using prostitute in Puerto Rico reported ‘uso condones
siempre con parejas pagadas (always uses condoms with her paid customers)
but not with her principal partner because ‘el no sabe que soy prostituta’ (he
doesn’t know that I’m a prostitute). A New York Puerto Rican crack
Denise Oliver-Velez is an ethnographer working with the National Development and Research Institutes,
Inc. New York, USA; Sherry Deren is a principal investigator with the National Development and
Research Institutes, Inc.; Ann Finlinson is an ethnographer at the Centre for Addiction Studies, School
of Medicine, Universidad Central del Caribe, Puerto Rico; Michele Shedlin is a principal investigator
with the National Development and Research Institutes, Inc.; Rafaela R. Robles is an investigator at
the Centre for Addiction Studies, School of Medicine, Universidad Central del Caribe, Puerto Rico;
Jonny Andia is a project director with the National Development & Research Institutes, Inc.; Hector
M. Colo ´n is a co-investigator at the Centre for Addiction Studies, School of Medicine, Universidad
Central del Caribe, Puerto Rico and Sung-Yeon Kang is a data analyst with the National Development
and Research Institutes, Inc. Address all correspondence to: Denise Oliver-Velez, National
Development and Research Institutes, Inc., 71 West 23rd Street, 8th Floor, New York, NY 10010,
USA; e-mail: firstname.lastname@example.org
Culture, Health & Sexuality
ISSN 1369-1058 print/ISSN 1464-5351 online © 2003 Taylor & Francis Ltd
denise oliver-velez et al.20
smoking prostitute reported ‘always using condoms with tricks’ but never
using them with her IDU partner, because ‘we both don’t like condoms’.
These are quotations from informants interviewed in the ARIBBA
Project (Alliance for Research in El Barrio and Bayamo ´n), a dual-site,
NIDA-funded qualitative/quantitative study of the HIV risk behaviours
of Puerto Rican drug injectors and crack smokers (Deren 1995). The goals
of ARIBBA are to understand the influences on HIV-related risk behavi-
ours among Puerto Rican drug users in New York and Puerto Rico. The
New York component is being conducted in East Harlem and the Puerto
Rico study site is in Bayamo ´n, part of the San Juan Metropolitan Area.
Puerto Rican drug users are at highest risk for AIDS among Hispanic
populations in the United States (Montoya et al. 1999). Rates of HIV
prevalence are also disproportionately high among Puerto Rican drug users
(Des Jarlais et al. 1989, 2000, CDC 1999).1 Infection rates are rising for
women of colour, specifically African-Americans and Latinas (CDC 1999,
Tortu et al. 2000). Within the Latina category, Puerto Rican women are
at the highest risk (NYC Dept. of Health 1999). Drug-using women face
even greater risks, since obtaining money for drug use often involves
prostitution (Shedlin and Oliver 1993, Paone et al. 1999). Sexual risk
behaviours among Puerto Rican drug users are influenced by type of drug
use, high incarceration rates, and socio-cultural attitudes.
HIV prevention eVorts with IDUs have been found to be more eVective
in reducing injection-related risks than risks related to sexual behaviours
(Stephens and Alemagno 1994, Coyle et al. 1998). Crack cocaine use has
been a focus of sexual risk reduction in many studies, due to its relationship
with high frequencies of unprotected sex (Shedlin et al. 1998, Tortu et al.
1998). Drug injectors and crack smokers are not independent groups; many
IDUs also smoke crack and some crack smokers are either current or
High rates of incarceration of drug users and a relationship between
incarceration and HIV risk has been identified in the United States and in
Puerto Rico. Rising incarceration rates and longer sentences for young
Hispanic men, and of men who are drug injectors and crack smokers, have
been reported (Nygard 1993, Hebert 1997), increasing exposure to sexual
and injection risks and subsequently for the risks for infecting others upon
release (Robles et al. 1993, Gore et al. 1995). Specific conditions of over-
crowding and violence, and lack of adequate medical facilities have been
identified in Puerto Rico (Kiersh 1983).
Cultural attitudes towards reproductive choices, the role of religious
beliefs, and gender issues in sexual decision making are variables in the
complex issues aVecting sexual risk behaviours. Among Puerto Rican
women who have chosen to use birth control, 45% choose tubal ligation
(CDC 1998). There is a long history of surgical sterilization in Puerto Rico
and among Puerto Rican women on the mainland (Robles et al. 1988,
Lopez 1993, CDC 1998). When queried about condom use, many drug
sexual risk behaviours of puerto ricans21
using Puerto Rican women replied ‘I had my tubes tied—I don’t need to
use condoms’. Yet there have been no HIV risk reduction campaigns
targeting women with tubal ligations.
Contrary to the popular belief that Puerto Ricans are overwhelmingly
Catholic in religious faith, there has been a recent upswing in conversions
to Evangelical Christian sects and other Protestant denominations that
were established on the island as early as the 1940s (Cintro ´n 1996). Many
church members hold conservative views on sex and reproductive choices.
Issues of male dominance or machismo in the Puerto Rican community,
both on the mainland and the Island, have been discussed in the literature
(Bourgois 1996, Torres 1998) but rarely has this been applied to concerns
about the ability of drug-addicted women to insist on condom use with
partners. Puerto Rican women have higher fertility rates that white women,
and make diVerent birth control choices, heightening the risks of exposure
to HIV (Borras 1984, CDC 1998).
These factors are further complicated by the socio-economic realities
of the drug-using sub-culture within an already disenfranchized minority
community (in New York) with high rates of poverty and unemployment
(in both New York and Puerto Rico) (US Census 1992). The desperate
needs of severely addicted users to acquire drugs may negate the impact
of and compliance with general public health messages, and aVects decisions
about whether or not to spend their last dollar on drugs or condoms.
The ARIBBA project utilized both qualitative and quantitative methods
to examine sexual risk behaviours. This paper is based primarily on
analysis of the qualitative data, with selected results from the survey
instrument used to provide further information regarding the distribution
and prevalence of selected behaviours. Participants in both components
provided informed consent, and all procedures were reviewed by the local
Institutional Review Boards.
The qualitative research teams consisted of an ethnographer and two out-
reach workers in New York, an ethnographer, ethnographic assistant, focus
group leader and interviewer in Puerto Rico, and an ethnographic consult-
ant to co-ordinate the research. Team members from each site visited the
other location to discuss methods and findings, and to conduct observations
to facilitate comparisons (Deren et al. in press). Ten focus groups (five in
each site) ranging in size from 7–12 participants were conducted with
female crack smokers, male IDUs, outreach workers, drug-using men who
have sex with men (MSM) (including gay-identified men), and recovering
addicts. Focus groups helped identify specific areas to be targeted in the
survey instrument, and were helpful when dealing with an active drug
using population of informants (Shedlin and Schreiber 1995).
denise oliver-velez et al.22
A series of in-depth Targeted Ethnographic Interviews (TEIs) were
conducted with 21 drug using Puerto Rican informants (11-NY/10-PR).
TEI informants were required to be Puerto Rican, active crack smokers or
injectors, at least one third were female, and ranged in age from 20–60.
Ongoing periodic observation of TEI informants was conducted in both
locations and field observations were conducted where drug users buy and
use drugs, and around treatment facilities and social service agencies.
Although no direct observation of sexual activity was conducted, observa-
tions took place in areas of sexual activity (crack houses, shooting galleries
and outdoor solicitation locations) and direct observations were conducted
of condom distribution.
All of the interviews and focus groups were transcribed and entered
into a series of ‘Info-bases’ created with Folio Builder/ Folio Views software
(Folio Corporation 1998) to build one qualitative database, shared by the
ethnographers from both sites.
A survey instrument was administered to 800 Puerto Rican active (verified
by urine test) IDUs and crack smokers, over the age of 18 in East Harlem,
NY and 400 in Bayamo ´n, PR (Deren et al. in press) from January 1998
through August 1999. There were some diVerences in the demographic
characteristics of the sample recruited in both locations: In New York:
73% were male, average age was 38.4; in Puerto Rico, 79% of the sample
was male, and the average age was 33.2. Overall, 44% were recent (prior
30 days) IDU, 27% were crack smokers, and 29% had used both.
Crack, sex and prostitution
The first responses from female focus group participants in New York to
questions about crack and HIV risk behaviours were health related. TB
and ‘pulmonia’ (pneumonia) were cited as risks. Several of the women
asked questions about whether or not the virus could be passed due to
cracked lips, open sores in the mouth or blood in or on the pipe. Only
after probing did any of the participants connect sexual behaviours due to
crack usage in relationship to HIV risk. All agreed that women who smoke
crack forget completely about using condoms. One woman in the New
York crack users group described her complete unwillingness to give
‘blowjobs’ to uncircumcised males, but ‘if they were circumcised, and
looked and smelled clean it was okay’. Slightly under half of the group
said crack made them ‘horny’. The others said that when they were smoking
they had no desire to have sex. Some women in the crack users group in
Puerto Rico felt that the use of crack makes men ‘bellaco’ (horny) but
when they have used it they are not able to perform sexually. ‘El 100% de
sexual risk behaviours of puerto ricans23
los hombres que se meten perico o crack, tu sabes, es bien poco el que se le puede
parar el miembro’ (100% of the men who use crack, you know, it is very
rare that they can get a hard-on). This drug-induced erectile dysfunction
often leads women to removing a condom in order to get the client to
ejaculate, which ends the transaction. Other women in the Puerto Rico
group stated that there is a big diVerence between the men and women
who smoke crack—that women have more control. Other studies of crack
using women report similar findings (Shedlin et al. 1998, Sterk 1999).
One woman stated that crack ‘turns her oV’ sexually (A mi me apaga la
droga). When asked where women get the money to buy crack one woman
replied, ‘prostitucio ´n, verdad, que es el vehı ´culo mas ra ´pido que tenemos
nosotras’ (truthfully, prostitution is the quickest method that we have).
Stories were told illustrating the risk of being forced to have sex without
condoms, or raped.
Julie, a 26-year-old HIV-positive crack smoker and street prostitute in
NY, born in Puerto Rico, described a crack house in Puerto Rico:
JULIE: It’s a basement like, and the person that’s running the basement you had to pay him
$20 up front … there was all women and men, older women, older men … girls oVer themselves
like, ‘Can I get a hit? Can I get a hit? Come on!’ You know? I’ll do este [this] you know mamando
el otro [sucking on the other] knowing that they could be friends, brothers or whatever. You
just finished this guy and the next one would go, and not even cleaning them up or nothin’!
INTERVIEWER: And not using condoms?
JULIE: No. Nobody. Because over there, I guess condoms for them was hard, was, is a hard
thing for them…
INTERVIEWER: What percentage do you think actually used condoms? … Many, half of
them, less than half?
JULIE: Yes. [less than half] And the guys too ... cause there are guys out there too. A lot of
them young. A lot of men didn’t want to use condoms … They wanted to feel it!
INTERVIEWER: So what did they say if you said anything about them putting them on?
JULIE: I was too high to think of it.
INTERVIEWER: Did any guys ever say, ‘Look I have a condom, I want to use it’.
JULIE: One or two. Out of just maybe a couple, I’d say 20 out of 100 … Some of them were
like, ‘I don’t fucking want the condom! Uck!’ I stopped even asking. So I just let it be, If they
wanted to it was on them.
Rubia, a 24-year-old, HIV positive female crack smoker and former
injector, born and raised in New York, describes a crack house in East
RUBIA: You could say a crack house is a whorehouse … Ah, it’s an apartment … There used
to be a lot of girls. Like around six girls, sometimes five … Blacks … and Puerto Ricans … And
they had a lot of guys, like around seven, eight guys … they used to talk to the girls like, ‘damn
you know what’s up, Baby do you wanna hit?’ ... then they use to treat us on crack and then if
we wanted more, or more money, they use to go, ‘yo bro, I’m gonna use the room for a minute,
alright’. We use to go to the room, sit down on the bed, smoke ... he use to throw me like
around, ten bottles, cause they had money.
INTERVIEWER: How much is the bottle?
RUBIA: Five dollars, three dollars … they use to use to say … ‘What you wanna do baby? …
And I used to get embarrassed, you know. But I was just thinking about the crack … He use
to lay down and smoke crack while I eat him up, you know and they use to take so long coming,
and I wanted to just leave and go and smoke my crack alone…
denise oliver-velez et al.24
Chinita, a 41-year-old HIV-positive injector and crack smoker, born and
raised in New York, describes an incident with a violent client, one of the
reasons she rarely does ‘car dates’ anymore:
INTERVIEWER: You don’t jump in cars?
CHINITA: Nah! Only with guys I know for years. Because, I almost got killed three times
behind that shit … The time, I got in the car and we’re supposed to go around the corner to
the room. The motherfucker kept riding, going straight. And I said, ‘yo, man not this way’.
When I went like that, ‘yo’ there’s a guy sitting in the back and grabbing my neck, with a knife.
He had me suck his dick all the way to Jersey, without no condom or nothing. I’m telling this
motherfucker ‘I’m positive [HIV]’. He said, ‘I don’t give a fuck’. He had his knife on my
neck … So we get to New Jersey, the one that was driving got out, paid for the room while the
other one had me in the back … I started running and screaming. And the one that’s opening
the door came running out and punching me right in my eye … I was still running. I had a big
black eye like that.
Heroin and sex
In the survey component, male IDUs (primarily heroin users) were less
likely to report engaging in sex in the past 30 days (see table 1). Members
of the New York focus group with male IDUs agreed that heroin users
had lower sex drives, and less risk sexually than crack users. In particular,
they discussed diYculties ejaculating while using heroin:
INTERVIEWER: Does heroin decrease your sexual desire over time?
ROMAN: It holds you back, it holds you back
GEORGE: You don’t reach your … you don’t come. You can be in it for like 10 hours on
heroin and you ain’t gonna come at all, you know what I’m saying you wind up falling asleep
and wake up the next morning…
CHINO: But what happens is with the crack you smoke and come and smoke and come and
do it again and just fuck.
This diYculty ejaculating during a heroin high could also increase the
likelihood of either removing a condom (if used at all), or condom breakage.
In the gay male focus group in Puerto Rico, a diVerence of opinion was
expressed about the aVects of heroin on sexual behaviour. For some, the
use of heroin reduced sexual desire, while for others it was sexually stimu-
lating. In Puerto Rico several of the IDU men indicated that they preferred
drug-using sexual partners because they would share drugs with them and
the partner would understand their need to use drugs. Many of the men
in the MSM group however, expressed a desire to have non-drug-using
partners, who would not demand a share of their drugs.
The survey data presented in table 1, reports on sexual risk behaviours
in the 30 days prior to the interview, separately by gender, for those who
reported recent injection, crack use, or both types of drug use (in the prior
30 days). Trading sex for money or drugs was reported more often in
Puerto Rico, and was highest for female crack users in Puerto Rico.
Sex risk and incarceration
The combination of unprotected sex and the sharing of unsterile syringes
while incarcerated, creates increased sexual risks for inmates, who may not
sexual risk behaviours of puerto ricans25
Table 1. Sexual risk behaviours among Puerto Rican drug users in New York and Puerto
Rico, by site, recent drug use, and gender.
New York Puerto Rico
(n=315) (n=239) (n=246) (n=210) (n=88) (n=102) Site
Behaviour in prior 30 daysa
Engaged in sex (%)
Traded sex for money or drugs (%)
% Unprotected vaginal sex
<0.001 <0.05 334150
aData on the per cent who engaged in sex are based on the total sample; all other variables
are based only on those who reported having sex in the prior 30 days.
bBased on chi-square tests.
be injectors, but who may become the partners of injectors. Some inform-
ants who considered themselves to be ‘straight’ initially hesitated to admit
to homosexual liaisons, but after probing expressed the opinion that there
were sexual HIV risks within the prison system. Men who have sex with
openly gay men and consider themselves straight were referred to as buga-
rones (buggerers). Jose, a 28-year-old heterosexual IDU, born in New York
but raised in Puerto Rico, was interviewed in New York and reported on
his prison experience in Puerto Rico:
INTERVIEWER: What about sex in jail?
JOSE: Ah! There’s a lot, a lot of that. I mean like not rape, or anything
INTERVIEWER: No, I’m talking about sex.
JOSE: There’s homos … you know, homosexual sex.
INTERVIEWER: They are not kept in a separate part of … the prison?
JOSE: No, not Puerto Rico. Maybe, here they do, no, not really neither. Depends if you …
‘cause you got homos they get married in jail. But they got their own man and they got diVerent
hours for them to shower … when they shower together that’s when they’re having sex … they
put a red towel, or a yellow towel over and you know you can’t go in that bathroom because
their man is in there with the homo so you can’t go in there. That’s like disrespect.
INTERVIEWER: So that’s like a signal? … And people respect that signal?
JOSE: Yeah, you’ve got to, you’ve got, that’s a violation.
INTERVIEWER: Well what do you mean it’s a violation?
JOSE: Well, shoot … you could get hurt. You could get, ‘cause over there in Puerto Rico
specially there’s a Associacio ´n N ˜eta you know, that’s a big organization. Mostly everybody is
got to live by the rules.
The N˜etas are a prison gang founded in the prisons of Puerto Rico, and
transplanted recently to the United States. N ˜etas have written and pub-
lished their codes of behaviour (Connecticut Correctional OYcers On-Line
1997, Prison Connections 1997a, b) which are called ‘normas’.
denise oliver-velez et al.26
Flaco, a 21-year-old injector and crack smoker, born in Rio Piedras,
and interviewed in Puerto Rico, reported on the lack of condoms:
INTERVIEWER: …los N˜etas tienen alguna regla que tenga que ver con el uso de condones dentro
de la prisio ´n?
FLACO: Adentro no tienen ni condones ni nada. Ahı ´ la gente es ası ´ como quien dice, perdonando
la palabra, un marico ´n de la calle, lo hacen casar porque lo hacen casar pero el marico ´n no sabe si
el tipo tiene HIV. Ahı ´ mismo es que se contagia.
INTERVIEWER: ¿O sea, que alla ´ dentro no se usan condones?
FLACO: Eso es ası ´, no se usan condones. No los dejan pasar, bueno por el tiempo que yo estuve
allı ´ nunca ha habido…
INTERVIEWER: …the N ˜etas have some rule that has to do with the use of condoms in prison?
FLACO: Inside they don’t have condoms or anything. The people as you say, excuse the word,
a faggot from the streets, they make him marry because they have to marry, but the faggot
doesn’t know if the guy has HIV. That’s when he gets contaminated.
INTERVIEWER: So inside there is no use of condoms?
FLACO: That’s how it is, condoms are not used. They are not allowed in, at least for the time
that I was inside, there were never any…
Junior, a 23-year-old crack-smoking informant interviewed in Puerto Rico,
was born in Rio Piedras, but spent time in New York City felt New York
incarceration was more dangerous. He described his horror watching a
rape of another inmate in jail in New York, and asserted that this could
not have happened in Puerto Rico due to ‘normas’ enforced by the N ˜etas,
stating that rape of an inmate is severely punished. He added that N ˜etas
practice their own methods of safeguarding against HIV risks:
JUNIOR: Lo que pasa con los N˜etas, que si uno esta enfermado con el SIDA, no puedes vivir en
el pueblo porque puedes contagiar a los otros presos, tu sabes, entonces se enferman todos los otros;
ellos tienen su parte, como un ‘detox’, los tienen ahı ´ metidos a los que esta ´n enfermos, los tienen
aparte, aunque sean N˜etas pero los tienen aparte a ellos.
JUNIOR: What happens with the N˜etas, it’s that if you are sick with AIDS, you can’t live in
the population because you can contaminate the other prisoners, you know, then all the others
get sick; they have their own place, like a ‘detox’, those that are in there are sick, they have
them separated, even if they are N˜etas, but they have them apart.
Survey data regarding experiences in jail/prison indicated similar levels
of sexual activities in New York and Puerto Rico jails/prisons (approxi-
mately 7% reported having sex when incarcerated) with none of the sample
in PR reporting condom use while incarcerated, compared with 24% in
New York. Higher levels of ever injecting in jail/prison were reported in
Puerto Rico (37% vs. 18% in New York), and sharing injection parapherna-
lia was reported by more than half of the participants in both sites (62%
in NY and 76% in PR).
Although we are usually presented with risks for men becoming infected
while incarcerated, and their potential for infecting others after release,
Felipe’s story is a bit diVerent. Aged 27, born in New York, and raised in
a small coastal town in Puerto Rico where there are many shooting galleries,
Felipe injects heroin and cocaine. He and his wife had been meticulous
about not sharing injection equipment, and used a needle exchange regu-
larly. They did not use condoms, he stated, because they were mono-
gamous. He reported providing the money for their drug use by doing
sexual risk behaviours of puerto ricans27
‘stick-ups of drug spots’, while his wife stayed home. During the course
of our observations of Felipe and his wife, he was arrested and sent to
prison for two years. During the time he was away, his wife, left with a
heavy cocaine habit and no means to support it, turned to trading sex for
drugs. Outreach workers observed her with multiple partners, and she was
interviewed, and tested for HIV during her husband’s incarceration. Upon
Felipe’s return from prison his wife did not inform him of her activities
while he was incarcerated. He believes that his wife is HIV negative and
was secure about his sexual relationship with her:
INTERVIEWER: You don’t have sex with anyone else?
FELIPE: No, nobody else. My wife she satisfy me in every need.
INTERVIEWER: And your wife doesn’t have sex with anybody?
Use of condoms
Injectors who were also sex-workers, when questioned about condom use,
initially reported ‘always using condoms’ but also reported that they are
oVered more money by clients who prefer not to use them. Gabriel, a
22-year-old HIV-positive homosexual injector, who works as a street pros-
titute in New York, describes the street sex scene:
GABRIEL: When I go out there to the streets, and I’m over here in this neighbourhood
(referring to East Harlem), it’s $20 for a blowjob and $40 for a fuck. If I go midtown … forty-
second, forty-third, … it’s $50 for a blowjob and a $100 for a fuck…
INTERVIEWER: When you give him a blowjob…
GABRIEL: …if I use condoms? … Sometimes, sometimes I do, sometimes I don’t. Sometimes
I got customers that oVer me more money without a condom. I would not have sex without no
condom. I know that much…
INTERVIEWER: You’re talking about anal or—
INTERVIEWER: Oh, OK, So, for anal sex you will use a condom.
GABRIEL: Yeah. Always. With Jerome [his lover] I would use no condoms...
INTERVIEWER: And Jerome knows your status?
GABRIEL: Yeah. He knows my status.
INTERVIEWER: What’s Jerome’s status?
GABRIEL: He’s HIV positive.
After discussions with Gabriel over several months his story changed. He
admitted that when he ‘falls in love’ with a date, he didn’t use condoms at
all, for fear the lover may think he has AIDS and leave him. He reported
he had a new lover, a young professional man, whose wife was in the
hospital having a baby. Gabriel has been visiting his house, had even
helped decorate it for her homecoming, and had repeated sexual encounters
with him, without a condom. Many other HIV positive respondents also
reported not using condoms with HIV positive partners, never discussing
risks for re-infection (it should be noted that whenever high-risk behaviours
were reported, information about risk reduction was provided either by
the ethnographic team or the project HIV counsellor).
denise oliver-velez et al.28
Chinita talked at length about her feelings about men who don’t want
to use condoms with her:
I told a man one time, ‘you must not love yourself’. He said, ‘what are you talking about?’ I
said ‘you don’t want to use a condom with me. You don’t even know me Mister. You don’t
know what I got. Or you just go around taking people’s word that they are okay?’
Some women in the crack-using focus group in Puerto Rico initially stated
they always used condoms, some said ‘usually’ or ‘used them most of the
time’. After probing ‘siempre’ (always) was changed to ‘aveces’ (sometimes).
One woman stated it depended on the client that came along (depende de
la persona que venga) another said it depended on the working girl (Eso
depende de la mujer que este ´ en el trabajo), another added that it depended
on the situation. Two women were in agreement that they always used
condoms to have oral sex, (but not necessarily for vaginal sex) because they
found oral sex without a condom to be repugnant (me da asco).
An HIV positive crack-using participant said she did not use condoms
with her partner very often because they had given her ‘pills’ at the clinic
to prevent her from infecting her partner. Several informants also said they
did not use condoms because they think their partner is ‘safe’.
Blanco, a 31-year-old HIV negative crack smoker in New York, at the
time of his first interview was in a relationship with a woman whom he
felt was ‘safe’. He said, ‘Ah, well, the times that I didn’t use [condoms]
was that I knew my partner wasn’t like in the streets or selling their bodies,
you know? That I knew that they were all right’. However, observations
by outreach workers told another story. They reported that the woman
Blanco was living with was trading sex for drugs with high-risk injectors,
which he was not aware of.
Jose ´, had mixed feelings about his sexual partner. He was not completely
sure about his current partner’s status (he met her at his methadone
programme). He did not want to hurt her feelings by insisting that they
use a condom, but expressed some of his unease during an interview:
INTERVIEWER: You don’t use condoms with her?
JOSE: No, no condoms, no … See if I tell her ‘well, let’s use a condom’, she’ll feel disrespected
whatever, so I don’t want her to feel that way, you know. Even though she tell me ‘I don’t do
nothing with nobody’ but you never know, you know, I don’t trust women, you know. So I
don’t know what she is doing, what she’s not doing. I met her in the street corner, so you know
she had to be doing something wrong the way she is on the programme and all that.
Site diVerences in condom access and use
There was general agreement in focus groups and interviews that there
was easier access to condoms in New York than in Puerto Rico. Informants
felt that drug users were more likely to use condoms in New York than in
Puerto Rico due to religion, culture and general availability, referring to
both free distribution and prominent display of condoms in pharmacies,
both more likely in New York.
Far more Catholics in our study reported condom usage than those
who have converted to, or are members of other denominations, and more
of the New York study participants reported that they were Catholic (73%,
sexual risk behaviours of puerto ricans 29
compared with 47% in PR). In the Puerto Rican sample, almost one-
quarter (27%) were Evangelical, compared with only 3% of the sample
recruited in New York.
Papo, an IDU focus group participant in NY who is from Puerto Rico
PAPO: Yo vengo de el caserio de Ponce. En lo pueblo mas que hay este SIDA, de mi pueblo de uno
de ellos de me caserio porque alli no estan repartiendo condones como los hacen aqui como en calle.
Alli, tu tiene que ir al hospital para que te den los condones, you know. No aqui, aqui te dar los
condones en la calle en la todos esquinas donde quiera, hay anuncio y eso.
PAPO: I come from the housing projects in Ponce. That’s the town with the most AIDS, in
my town they are not handing out condoms like they do here in the street. There you have to
go to the hospital so that you can get condoms, you know. Not here, here you got condoms in
the streets in every corner, there are ads and all.
DiVerences in cultural norms
DiVerences in cultural norms in the two locations were addressed by several
informants. Tomaso, a 42-year-old ‘speedball’ (heroin and cocaine mixed)
injector born in New York but living in Puerto Rico when interviewed,
felt that behaviours in Puerto Rico were influenced by the small-town
nature of the communities that drug users live in and their lack of
TOMASO: Bueno es que en Estados Unidos son mas liberales, en Estados Unidos nadie esta ´
pendiente a nada de lo que tu hagas es lo que pasa y tu, en Estados Unidos puedes hacer lo que tu
quieras hacer, que ningu ´n vecino va a estar pendiente a lo que tu hagas o va estar diciendo ‘Mira,
tu sabes que fulano esto’ casi nadie te conoce, no es como en Puerto Rico que en la urbanizacio ´n
donde yo vivo, llevo 30 an ˜os viviendo ahı ´ to’ el mundo conoce a to’ el mundo y si me ven a mı ´
haciendo cualquier cosa ya aquella se lo dice a aquel…
TOMASO: Well it’s that in the United States they are more liberal, in the United States nobody
pays attention to what you are doing, that’s what happens and then in the United States you can
do whatever you want, the neighbours are not going to be watching you and saying ‘Look, you know
that so and so this’, hardly anyone knows you, it’s not like Puerto Rico, where the community that
I live in, I’ve been living there 30 years and everybody knows everybody, and if they see me doing
something one person tells another…
Lydia, a 40-year-old crack smoker and cocaine injector who had recently
arrived in New York from Puerto Rico, where she was born and raised,
was oVended by the aggressive distribution of condoms on the street in
LYDIA: Puerto Rico is not like in here … you know you use it, this and that, you go and buy
them … Oh no we are very, very open minded and we are very conscious in that but it’s not
like in here [NY]. Everywhere you go you got condoms you know … We ain’t that explicit.
INTERVIEWER: It’s too open?
LYDIA: Too open. It’s not that we better, but it’s too open, that push you into things…
INTERVIEWER: So you’re saying that things are more private?
LYDIA: They, they … put people to be promiscuous in here. It’s too open … You gotta make
people aware of the dangers that they’re getting into, come on, don’t be so pushy. Sometimes
you don’t wanna take the condom and they keep on top of you, ‘here, here’. You don’t know if
I’m a lesbian, why you gotta be giving me condoms for? The other day I got this man oVering
condoms, Yo, Yo, you don’t know me ... why you gotta say that I need it. Why so pushy for
denise oliver-velez et al.30
me to take your condoms? … what the fuck is wrong with you? Why you gotta say that I’m
gonna need it and I’m gonna regret it if I don’t take it? … Use it yourself then!
However Felipe, thought the availability of condoms and other services in
New York is a good thing:
FELIPE: In New York we got so many programmes everywhere, methadone programmes and
the addicts, we got so much help from the City. You know we got needle exchange, they give
us condoms. Like yesterday I was in 125th Street and this Sir giving me a bag a condoms …
In Puerto Rico we don’t got none of that … Nothing, no condoms in the streets. I haven’t seen
no pamphlets about AIDS.
Other opinions about condom use and the diVerence in culture were
expressed in the focus group with IDU men in New York:
ROMAN: In Puerto Rico, they don’t believe in condoms. Because sex is like a very…
ROMAN: Yeah, sacred. And, it’s more like making love to the woman.
FLACO: You think they’re virgins, they don’t got it [referring to AIDS].
ROMAN: It’s people don’t like using condoms.
LOPEZ: Like me, I don’t wear them, I don’t like them, man [Lopez is HIV positive].
EDDIE: That’s why the population of AIDS is so great.
ROMAN: That’s why we have the problem over there that you have … if you want to call it
old fashioned, cause the way people’s life styles are in Puerto Rico … Condoms is something
that’s like 90s … A woman and a man don’t, they both don’t want to use it. In New York it’s
diVerent. But in Puerto Rico that’s the way it is.
INTERVIEWER: Why do you think it’s diVerent here?
ROMAN: Because it’s culture. It’s more old fashioned, like I said.
Some of the male group members in the recovery group felt that the
same man would behave diVerently in diVerent sites, that he would be less
likely to use condoms in Puerto Rico, and that women in New York would
insist on condom use. The lone dissenter was a female, who said men were
‘diYcult’ in both places due to machismo. In the Puerto Rico recovery
group, the discussion of sexual risk centred on ‘protection’ and disclosure
issues, with one participant stating he felt women in New York were more
likely to disclose that they are HIV positive because it is a more liberal
environment. A woman disagreed, saying she felt there was no diVerence,
and another woman added that HIV positive women in Puerto Rico remain
silent about their status.
Survey data indicated that although the New York male participants
had greater access to condoms than males in Puerto Rico (see table 2),
there was no significant diVerence between females. Specific eVorts have
been underway to increase condom availability for female sex workers in
the Bayamo ´n community in Puerto Rico (accounting for lower rates of
unprotected sex among females crack users (see table 1). Free condoms
were much more likely to be available in New York, with about 75% of
male and female participants in New York reporting that they had received
condoms from a community worker and 35% from needle exchange pro-
grammes. In Puerto Rico, there were higher reported rates of purchasing
condoms from pharmacies.
sexual risk behaviours of puerto ricans31
Table 2. Condom availability for Puerto Rican drug users by recruitment site and gender.a
Behaviour in prior 30 days
Received or purchased condoms
Needle exchange programme (NEP)
aBased on those reporting sex in the prior 30 days.
bBased on chi-square tests.
Conclusions and recommendations
Advances have been made in recent years in HIV prevention, including
increasing drug users’ awareness of injection risks, designing outreach
interventions withbleach kitsand
Programmes (NEPS). Data collected in ARIBBA, however, indicate that
we must increase our eVorts in addressing sexual risks for both injection
drug users and crack smokers. Although there are some important site
diVerences, additional prevention eVorts are needed in both locations.
establishing Needle Exchange
Enhancing outreach and prevention messages
More education eVorts are needed in the Puerto Rican community to dispel
myths about sexual partners who ‘look clean’ or appear to be ‘safe’.
Enhanced outreach and intervention for crack users, specifically women
and MSMs, are needed in both sites. In addition, programmes specifically
designed to for street sex workers should be expanded. Organizations that
do outreach and provide services for gay men need to enhance outreach to
gay men of colour who are drug injectors and crack smokers.
Enhancing condom use
EVorts should be made to increase free condom distribution in Puerto
Rico, given the high frequency of sex for drugs or money for drugs.
However, care should be given to design a programme of distribution that
does not oVend the cultural sensitivities of the target population. Since
many of the women in the study in Puerto Rico indicated that they have
to purchase condoms from pharmacies, and have large numbers of paid
denise oliver-velez et al.32
sexual partners, further study is needed to determine the frequency of
purchase, and their decision-making about when to purchase, and in what
Alternative methods of protection need to be developed and made
available for those people uncomfortable with the use of the male condom.
Though female condoms have been developed, few actually reach the
women who do sex work, due to their high cost.
Enhancing prevention eVorts among women
The data indicate that additional eVorts, specifically targeting women, are
needed to address two particular issues: (a) AIDS education and prevention
campaigns, targeting those Puerto Rican women who have had tubal liga-
tions, should be developed. Hospital and clinic staVs, specifically obs/gyn
personnel, should receive training in harm reduction and HIV/AIDS edu-
cation to better serve and educate female patients who are using non-HIV-
protective contraceptive measures; (b) support and training for Puerto
Rican women in techniques for asserting their rights to be protected,
and training/support groups to address male issues and machismo as it
relates to sexual decision making are needed. These services can be pro-
vided through a variety of providers, including community health service
providers and drug treatment facilities.
Enhancing prevention eVorts in jails/prison
Lack of access to condoms in jails and prisons should be addressed in both
locations. Further study is needed on the impact of Association N ˜eta and
other jail and prison groups such as Latin Kings and La Familia normas/
codes on sexual risks in prison. Youth outreach teams should implement
eVorts to contact and educate gang leadership about HIV risks to their
membership. The high rates of risky injection-related behaviours in jails/
prisons confirms reports from our qualitative data as well as many other
studies (Dolan et al. 1996, Mahon 1996), and requires further attention. A
range of recommendations can be made to address this, and discussions
within local criminal justice venues may be helpful in identifying steps to
initiate, which can include enhancing drug treatment services in jail/prison
Methodologically, this paper demonstrates the utility of integrating
qualitative and quantitative data, in enhancing our understanding of HIV
risk behaviours. Results derived from longitudinal qualitative data collec-
tion, based on developing rapport with participants, indicates that more
detailed and representative information can be obtained over time, e.g.,
initial reports that condoms were ‘always’ used were modified to enable us
to understand that there were circumstances under which ‘always’ became
‘sometimes’ or ‘never’. These data assist in the interpretation of the quantit-
ative data, indicating not only the context within which the behavioural
prevalence data should be understood, but also that there may be some
sexual risk behaviours of puerto ricans33
over-reporting of the more socially desirable behaviours, e.g., the extent
of condom use. The need to continue the integration of qualitative and
quantitative data collection and analyses is of critical importance for
developing the most eVective HIV prevention programmes.
It is our hope that data from the ARIBBA study will be used by public
health service providers, policy makers, drug treatment programme direc-
tors and staV, and other organizations who have contact with Puerto Rican
drug users and their sexual partners to design more eVective programmes
and education eVorts and to enhance funding for such eVorts.
This research was based on a project funded by the National Institutes on
Drug Abuse, Grant #R01DA10425. The authors would like to acknow-
ledge the ethnographic and outreach teams in both locations: Nadina Correa
(NY), Myra Soto (PR), Ray Monserrate, (NY); interviewers, Maria del
Carmen Negro ´n (PR), Gladys Torres, Romulo Gil (NY) and Denise
Santana (PR); and field site managers Rosa Arroyo (NY) and Wanda
1.Though not an independent nation-state, Puerto Ricans are referred to by others and by themselves
as a national group, and as an ethnicity. The Commonwealth of Puerto Rico (Estado Libre Asociado
de Puerto Rico) is a self-governing commonwealth in association with the USA. Although Puerto
Ricans are US citizens, residents of Puerto Rico pay no federal income tax, nor can they vote in
presidential elections. In general, Puerto Ricans refer to themselves as ‘Puertorriquen ˜os’ or
‘Boricuas’. For most Puerto Ricans, ‘my country’ (mi patria) means ‘Puerto Rico’, not the United
States. Political views on the relationship between the USA and Puerto Rico range from a movement
for independence, a movement towards statehood, and the majority in the middle have voted to
maintain the status quo. Throughout the text—references and comparisons are made between island
and mainland—however all informants interviewed wherever they were born, living or raised
considered themselves to be Puerto Ricans, first, and some secondarily ‘Americans’.
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