Decline in HIV-1 seroprevalence and low seroconversion rate among injecting drug users at a methadone maintenance program in New York City

To monitor the trend of HIV-1 seroprevalence, 2,194 newly admitted injecting drug users (IDUs) in a methadone maintenance program in New York City were tested from June 1988 through June 1992. This was a blinded study and unlabeled blood specimens were collected during the required physical examination. There was a significant linear trend (p = .01) toward decline in HIV-1 seropositivity by year of admission as follows: 47.0% in 1988, 43.4% in 1989, 43.2% in 1990, 39.8% in 1991, and 39.1% in 1992. From January 1988 through December 1992, admissions data that included the newly admitted IDUs showed a significant decrease (p < .0002) in self-reported current needle sharing from 11.3% to 5.4%. These two data sources suggest that a continued decline in HIV-1 seroprevalence among new admissions may be related to decreased needle sharing. A volunteer cohort of 235 HIV-1 seronegative IDUs was also enrolled from April 1990 through June 1991 in a study of HIV-1 seroconversion. Follow-up data were available on 177 patients for up to 12 months. For a total observation time of 155 person-years, there were two conversions (1.3 conversions per 100 person-years). A continued decline in HIV-1 seroprevalence among new admissions and a low HIV-1 seroconversion rate among existing patients have contributed to a lower overall HIV-1 prevalence in clinic patients of about 40%. This stands in contrast to 1985-86 estimates of HIV-1 seroprevalence that plateaued at 60%.

Short-term declines in CD4 levels associated with cocaine use in HIV-1 seropositive, minority injecting drug users

This study evaluates the association of cocaine use with short-term change in CD4 counts among human immunodeficiency virus type 1 (HIV-1) seropositive, minority injecting drug users prior to the introduction of zidovudine (AZT). Ninety-eight HIV-1 seropositive subjects were recruited from six inner-city, methadone maintenance clinics. A baseline assessment included a short questionnaire regarding drug behavior and quantitation of CD4 cell counts. These measures were repeated on all subjects 3 to 4 months later. Thirty-eight subjects reported using cocaine between baseline and 4-month follow-up evaluations. Males and African Americans were more likely to be cocaine users (P < .01). Cocaine users were more likely to engage in heroin and needle use (P < .001). Cocaine users experienced a significant decline in CD4 cells compared with nonusers (P = .013); no marked difference in CD4 decline was noted between heroin users and nonusers (P = .19). Multivariate analysis showed that a decline in CD4 counts was 2.82 times more likely to occur in cocaine users than in cocaine nonusers (90% two-sided confidence interval of 1.08, 7.37). These findings support the hypothesis of a possible link between cocaine use and short-term CD4 decline in HIV-1 seropositive injecting drug users.

Conflicting measurements of depression in a substance abuse population

Methadone maintenance patients (N = 217) were administered a computerized screening version of the National Institute for Mental Health (NIMH) Diagnostic Interview Schedule (DIS), the Beck Depression Inventory (BDI) and the Addiction Severity Index (ASI) 2-4 weeks after treatment entry. Few differences were found between African-American, Hispanic, and Caucasian subjects. Only 1.7% of the patients met a lifetime diagnosis of major depressive disorder, and 1.4% qualified for a current diagnosis major depressive disorder. In contrast, 35.8% of the patients reported moderate to serious depression on the BDI during the previous week, and 19.3% reported serious depression during the previous month on the ASI (38.7% lifetime depression). Because moderate correlations were found between the DIS, the BDI, and the ASI measures of depression, there is some indication that they were tapping a similar construct. Therefore the lower rates of depression found with the DIS are probably attributable to its more stringent definition of depression. The findings tend to confirm previous literature indicating that the DIS, as contrasted with other structured psychiatric interviews, underestimates depression.

Addiction Severity Index scores of four racial/ethnic and gender groups of methadone maintenance patients

This report compares the findings for four racial/ethnic and gender groups of methadone maintenance (MM) patients--African-American men (n = 153), African-American women (n = 107), Hispanic men (n = 138), and Hispanic women (n = 70)--administered the Addiction Severity Index (ASI). African-American men had a history of more arrests and incarcerations than Hispanic men. African-Americans had a longer history of drug and alcohol abuse problems than Hispanics and more current alcohol problems. Women reported more medical, psychiatric, family-social, and employment problems than men. Men reported more legal and alcohol-related problems than women. With several exceptions, the study findings were consistent with those based on other instruments. Given the relatively large sample sizes, the data may provide a characteristic ASI profile of the racial/ethnic and gender groups studied. The implications of differential group problem levels for substance abuse treatment efforts are discussed.

Enrollment of drug abusers in HIV clinical trials: a public health imperative for communities of color

There is an increasing appreciation of the impact of drug abuse on AIDS in the United States because of the pivotal role of injecting drug use in the prevalence of total AIDS cases and case reporting among ethnic/racial minorities, women, and children. While the participation of injecting drug users (IDUs) in HIV clinical trails has increased steadily, the IDU accrual rate lags unacceptably behind the IDU proportion of AIDS cases. The stigma of drug abuse, issues related to poverty, and the underrepresentation of communities of color are the major obstacles to IDU participation in HIV clinical research. It is critical to overcome these obstacles as the spectrum of HIV disease in IDUs requires the development of an IDU-relevant scientific agenda for HIV clinical trials. This, in turn, is crucial to the development of effective therapies for the treatment of HIV disease in IDUs. To the extent that these endeavors are successful, more relevant therapies to communities of color will be developed, as injecting drug use is disproportionately more prevalent in these communities.

No seroconversions among steady sex partners of methadone-maintained HIV-1-seropositive injecting drug users in New York City

OBJECTIVE

To assess the incidence of heterosexual HIV-1 transmission from seropositive methadone-maintained injecting drug users (IDU) to their seronegative, non-IDU steady sex partners.

DESIGN

A prospective, longitudinal study.

SETTING

HIV-1-seropositive IDU and their HIV-1-seronegative, non-IDU steady sex partners were recruited from six methadone-maintenance clinics in the New York City boroughs of Brooklyn and Manhattan.

PATIENTS, PARTICIPANTS

Between December 1988 and October 1991, 60 research participants were recruited [30 methadone-maintained, HIV-1-seropositive IDU (index subjects) and their non-IDU HIV-1-seronegative steady partners]. Baseline and follow-up (every 3-4 months) data included a structured questionnaire and blood testing for HIV infection and CD4+ cell subsets.

RESULTS

Demographic characteristics of the 30 steady sex partners were evaluated as follows: sex (22 women, eight men); age (mean, 32 years; range, 21-55 years) and race (African-American, 13; Hispanic, 13; other, 4). The average duration of relationship between index subject and partner at study entry was 7.5 years (range, 4 months to 19.4 years). At entry, 27 of the 30 partners reported no or intermittent use of condoms with the index subject during a typical 12-month period. Follow-up data (median follow-up, 298 days; range, 85-992 days) were available for 22 partners. Of these, 15 reported no or intermittent condom use. For a total study observation time of 23 person-years, there were no seroconversions. The upper 95% confidence interval for the observed seroconversion rate of 0% is 13%.

CONCLUSIONS

These results suggest that the likelihood of heterosexual HIV-1 transmission from seropositive methadone-maintained IDU to their seronegative, non-IDU steady sex partners is low.

A multicomponent model for substance abuse treatment. The Addiction Research and Treatment Corporation

This paper reviews the activities of the Addiction Research and Treatment Corporation (ARTC), a substance abuse treatment agency, located in Brooklyn, New York, which services approximately 2,300 patients annually. ARTC's history, treatment, and research activities are first described. We then proceed to detail the ARTC's employee health maintenance and community relations programs. A multicomponent treatment model is then outlined, which emphasizes the interactive role of the above functions within an optimal treatment network.

Endocrine complications of AIDS and drug addiction

The endocrine and metabolic consequences of illicit drug use and HIV disease are extensive and profound. Both narcotic drug use and AIDS have the capacity to cause clinically significant multiglandular derangements. Admittedly, we were not able to focus as much attention on the less frequently occurring disturbances of calcium, phosphorus, or folate metabolism in HIV disease. Similarly, we reported very little information about the endocrinologic significance of the use of classes of narcotics other than opiates and to a far lesser extent cocaine. Even with these limitations, the spectrum of drug abuse and HIV-related endocrine manifestations discussed previously is quite diverse. Given the pervasive effects of drug abuse on other organ systems, it is not surprising to find expanding interest in the endocrine consequences of narcotic drug use. In fact, the use of these drugs is responsible, in part, for the past and continuing interest in identifying receptors for these agents and similarly structured endogenous ligands. As these investigations proceed, we must appreciate the limitations in translating basic and clinical scientific findings to the clinical setting. Much of the current research does not study street-relevant narcotic doses, does not use research designs involving polydrug use, and does not involve the processes or routes of drug administration used by active narcotic addicts. There is a critical need for more research methods with animal models and clinical study settings that more adequately mimic drug use outside of the laboratory. Our ability to develop appropriate psychopharmaceutical agents to respond to the different faces of drug abuse in the United States will depend on continued progress in the area of neuroendocrinology. With respect to the consequences of HIV disease, the clinical findings of elevated hormonal levels in some endocrine systems are amazing given what one would expect if one postulated direct or indirect destruction by HIV or the opportunistic complications that accompany AIDS. In unraveling this puzzle, careful attention must be given to evaluating the degree to which the clinical or biochemical consequences are due to a direct HIV effect, to an effect of a complicating infection or neoplasm, or to an AIDS-related therapeutic intervention. More work is needed also in obtaining histopathologic information to correlate with the biochemical and clinical derangement. In summary, there is a wealth of information demonstrating a wide spectrum of endocrine/metabolic consequences of drug abuse and AIDS. Still, just as many questions remain unanswered. While the exact biologic mechanisms are unclear, many of the biochemical aberrations have clinical relevance.(ABSTRACT TRUNCATED AT 400 WORDS)

Hematological indices in a cohort of HTLV-I/II and HIV-1 infected intravenous drug users in New York City

The prevalence and clinical consequences of human T-cell lymphotropic viruses types I and II (HTLV-I/II) infection in human immunodeficiency virus-1 (HIV-1) infected persons are areas of continuing interest. This article reports the preliminary findings of the hematological indices in 454 patients infected with HIV-1 and HTLV-I/HTLV-II. Based on serology, 46.2% of the patients had evidence of HIV-1 infection only, 4.6% had evidence of HTLV-I/II only, 14.3% had evidence of both HIV-1 and HTLV-I/II, and 34.8% had evidence of neither HIV-1 or HTLV-I/II. The patient group with both HTLV-I/II and HIV-1 infection had lower total white blood cell, platelet, and serum hematocrits than patients with either HIV-1 or HTLV-I/II infection. While these differences were insignificant, they do not suggest any HTLV-I/II-induced protective effect against HIV-1 related hematological consequences.

Sexual behaviors and HIV infection in intravenous drug users in New York City

Heterosexual transmission of HIV infection is closely linked with intravenous drug use. This study investigated the sexual behaviors of intravenous drug users (IVDUs) in New York City. In 1986, 284 IVDUs were recruited from newly enrolled patients in methadone treatment clinics. A questionnaire asking for information on sexual behaviors was administered and sera were collected and tested by ELISA and Western Blot techniques. Associations between behavioral data and HIV serology were evaluated using univariate methods of analysis. HIV infection was significantly associated with age (p = 0.01). Subjects not claiming prostitution were also significantly more likely to be infected (p = 0.01). Subjects reporting condom use and oral sex had lower infectivity rates. Higher infection rates were observed in subjects reporting anal sex and homosexual or bisexual sexual behavior. The findings of this study suggest that greater efforts to isolate those sexual behaviors that are predictors or correlates of heterosexual transmission of HIV infection is much needed in order to design behavioral interventions that will effectively curtail the spread of this virus.

AIDS-related behavioral research and nursing

As efforts targeted at producing an effective vaccine or a definitive cure are still in early stages of development, health education and prevention continue to be this country's major line of defense against acquired immunodeficiency syndrome (AIDS). This defense is dependent on knowledge of behaviors that place individuals at risk of human immunodeficiency virus (HIV) exposure and disease progression. This article reviews the critical points in our state of knowledge and offers additional areas of need. Research is needed to determine a database of persons who use psychoactive substances and to understand the HIV-associated behaviors linked to drug use. Epidemiologic studies are necessary to appreciate the sexual, contraceptive, and childbearing practices of users of any psychoactive substance. Greater emphasis also is needed to investigate the inherent effects of various psychoactive substances on the immune, neurologic, and endocrine systems. While biomedical research continues, it is apparent that research from behavioral studies are crucial to education and prevention efforts. Nurse investigators are well-positioned to play an important role in accumulating this information. Given the critical role of drug abuse in the HIV epidemic, the public health significance cannot be overestimated.

Effect of psychological factors on risk behavior of human immunodeficiency virus (HIV) infection among intravenous drug users (IVDUs)

The effect of psychological factors on drug and sexual behaviors in relation to HIV infection was investigated among 262 IVDUs in methadone clinics in New York City. Among female IVDUs, the HIV positive subjects reported larger numbers of sex partners than those subjects who were HIV negative, and those who had larger numbers of sex partners were more likely to be depressed. The IVDUs who had larger numbers of needle-sharing partners at shooting galleries were more likely to be HIV positive. Intervention programs should focus on IVDUs who are sexually active females, sharing needles at galleries, still using heroin and cocaine, and who began using heroin at an early age.

Seroepidemiology and clinical aspects of human T-cell lymphotropic virus type I/II infection in a cohort of intravenous drug users in New York City

To define further the magnitude, epidemiology, and clinical features of human T-cell lymphotropic/leukemia virus type I/II (HTLV-I/II) infection in 454 intravenous drug users in New York City, we evaluated previously frozen aliquots of sera for HTLV-I/II antibodies using enzyme-linked immunoassay, Western blot, and radioimmunoprecipitation techniques. We found HTLV-I/II infection in 18.9% of the subjects. Age (p = 0.001), race (p = 0.001), having a same gender sexual relationship (p = 0.01), and HIV-1 infection (p = 0.041) were clear correlates of HTLV-I/II infection. HTLV-I/II seropositive subjects, in contrast to seronegative subjects, had lower leukocyte counts (p = 0.05) and higher globulin (p = 0.005) and gamma globulin (p = 0.009) levels even when HIV-1 serostatus was controlled. The considerable prevalence of HTLV-I/II infection and the morbidity of HTLV-I/II-associated disorders strongly suggest a continued need to define the dimensions of HTLV-I/II infection.

Death, AIDS morbidity, and HIV seroprevalence in New York City intravenous drug abusers

Drug treatment programs represent a point of access to intravenous drug abusers and, as such, may also be useful in monitoring health status indicators among this population. Such a surveillance project was established in 1985 among drug treatment clinics in New York City to monitor the human immunodeficiency virus (HIV) epidemic. HIV seroprevalence was 54% (255/469) in 1985, 61% (159/262) in 1986, and 60% (133/222) in 1987. Of the 2500 cumulative enrollees in these clinics each year, 4 patients met the Centers for Disease Control acquired immunodeficiency syndrome (AIDS) surveillance definition in 1985, 37 in 1986, and 37 in 1987. There were 25 AIDS-related deaths in 1985, 8 in 1986, and 16 in 1987. These results suggest that by including drug treatment programs in a rational surveillance system, we may be able to monitor the HIV epidemic more closely. The public health significance of such a surveillance program is magnified given the association between intravenous drug abuse-associated AIDS and the prevalence of AIDS among women, children, and ethnic/racial minorities.

Heterosexual transmission of human immunodeficiency virus among intravenous drug users

To examine sexual transmission of human immunodeficiency virus (HIV) among heterosexual intravenous drug users (IVDUs), HIV antibody status of IVDUs with intravenous drug-using sexual partners (IVSPs) was compared with that of IVDUs with no IVSPs. Initial bivariate analyses indicated IVDUs with IVSPs were more likely to be HIV antibody-positive than those with no IVSPs. Analyses by gender indicated that this relationship held for men but not women. IVDUs with IVSPs also differed from those without IVSPs demographically, in drug use, and in other sexual behaviors. When effects of other variables were controlled, no statistically significant relationship was found between injection history of sex partners and HIV status for the total sample or separately for men or women.

Patterns of HIV-1 and HTLV-I/II in intravenous drug abusers from the middle atlantic and central regions of the USA

Seroprevalence of human immunodeficiency virus type 1 (HIV-1) and human T lymphotropic virus types I and II (HTLV-I/II) was determined among 1160 intravenous (iv) drug abusers from five drug treatment or medical centers (Manhattan, Brooklyn, New Jersey, Detroit, and New Orleans). HIV-1 infection ranged from 5% in New Orleans to 48% in New York City. Hispanics and blacks had a significantly higher rate of HIV-1 infection than whites (P less than .01), but within each group rates were similar between males and females and by age stratum. HTLV-I/II seroprevalence increased with age from 3% in the 20-29 year age group to 37% in the group greater than 50 years. New Orleans and Manhattan (24%) had the highest rate, and blacks (19%) had a higher rate than either Hispanics (6.3%) or whites (7.3%). No association between HIV-1 and HTLV-I/II infection was observed except in Manhattan. When compared with iv drug abusers infected only with HIV-1, dually infected subjects had more clinical symptoms related to immune deficiency but a lower prevalence of HIV antigenemia. These data document the frequent occurrence of retroviral infections in iv drug abusers. The contrast between the two classes of virus suggests that HIV-1 is more efficiently transmitted, while the age-dependent rise in HTLV-I/II seroprevalence suggests cumulative exposure of a less-transmissible agent.

Serologic investigations in a New York City cohort of parenteral drug users

Human immunodeficiency virus (HIV) infection continues to be a major health problem for society. Intravenous drug users are the second largest risk group for HIV infection. The disease primarily affects immunologic functioning. This study examined the inherent immunologic dysfunction by measuring the seroprevalence of infection against pathogens often associated with HIV infection. Additionally, chi square analysis was used to compare intravenous drug users with a non-drug-using control group to see if any difference existed in the prevalence of antinuclear antibody, rheumatoid factor, abnormal titer of antibody to Toxoplasma gondii, cytomegalovirus, and herpes simplex virus (types 1 and 2). The intravenous drug users had a significantly greater level of antibody titers for antinuclear antibody and Toxoplasma gondii than did controls. Abnormal serologic results were not significantly associated with HIV seropositivity. The findings of this study suggest that intravenous drug users experience a greater prevalence of alteration in serologic markers unrelated to HIV exposure.

Human immunodeficiency virus infection in a cohort of intravenous drug users in New York City. Demographic, behavioral, and clinical features

In 1985, 454 intravenous drug users were recruited from among patients scheduled for physical examination in methadone treatment clinics in New York City. A questionnaire was administered, and serum was collected for human immunodeficiency virus (HIV) serology. The HIV seroinfection rate was 60.6%, with antibody and antigen detected in 58.4% and 4.3%, respectively, of the population. Nineteen percent of 307 subjects were in Group III or Group IV of the Centers for Disease Control (CDC) classification system for HIV-associated infections. Only behavioral factors (p = 0.001) and clinical indicators (p = 0.003) were found to distinguish the HIV-infected from the non-infected subjects. Frequent use of intravenous drugs (p = 0.016), duration of drug use (p = 0.050), and duration of drug treatment enrollment (p = 0.038) were significantly associated with HIV seroinfection status and CDC stage of HIV disease. These findings strongly support aggressive efforts to reduce parenteral drug use and enroll intravenous drug users into effective drug treatment programs.