Theorizing "Big Events" as a potential risk environment for drug use, drug-related harm and HIV epidemic outbreaks

Political-economic transitions in the Soviet Union, Indonesia, and China, but not the Philippines, were followed by HIV epidemics among drug users. Wars also may sometimes increase HIV risk. Based on similarities in some of the causal pathways through which wars and transitions can affect HIV risk, we use the term "Big Events" to include both. We first critique several prior epidemiological models of Big Events as inadequately incorporating social agency and as somewhat imprecise and over-generalizing in their sociology. We then suggest a model using the following concepts: first, event-specific HIV transmission probabilities are functions of (a) the probability that partners are infection-discordant; (b) the infection-susceptibility of the uninfected partner; (c) the infectivity of the infected--as well as (d) the behaviours engaged in. These probabilities depend on the distributions of HIV and other variables in populations. Sexual or injection events incorporate risk behaviours and are embedded in sexual and injection partnership patterns and community networks, which in turn are shaped by the content of normative regulation in communities. Wars and transitions can change socio-economic variables that can sometimes precipitate increases in the numbers of people who engage in high-risk drug and sexual networks and behaviours and in the riskiness of what they do. These variables that Big Events affect may include population displacement; economic difficulties and policies; police corruption, repressiveness, and failure to preserve order; health services; migration; social movements; gender roles; and inter-communal violence--which, in turn, affect normative regulation, youth alienation, networks and behaviours. As part of these pathways, autonomous action by neighbourhood residents, teenagers, drug users and sex workers to maintain their economic welfare, health or happiness may affect many of these variables or otherwise mediate whether HIV epidemics follow transitions. We thus posit that research on whether and how these interacting causal pathways and autonomous actions are followed by drug-related harm and/or HIV or other epidemics can help us understand how to intervene to prevent or mitigate such harms.

Multiple infections and associated risk factors among non-injecting cocaine users in Argentina

The aim of this study was to estimate the seroprevalence rates of human immunodeficiency virus (HIV), hepatitis B virus (HBV, core antibody), hepatitis C virus (HCV), and syphilis infections and analyze associated risk factors among 504 non-injecting cocaine users (NICU) in Buenos Aires, Argentina. Participants were interviewed in face-to-face sessions through a short structured questionnaire. Using venipuncture, 10 mL of blood was collected. Seroprevalence rates were: HIV (6.3%), HBV (9%), HCV (7.5%), and VDRL (4.2%). The risk of being infected with HIV, HBV, and HCV was significantly associated with having had a sex partner who was either a drug injector or who was known to be HIV positive. HIV and HCV infections were associated with former imprisonment, and HCV was associated with having been tattooed. Because of the rising number of NICU and the multiple infections detected, it is essential to implement prevention strategies focused on this population.

Estimating the prevalence of injection drug use among black and white adults in large U.S. metropolitan areas over time (1992--2002): estimation methods and prevalence trends

No adequate data exist on patterns of injection drug use (IDU) prevalence over time within racial/ethnic groups in U.S. geographic areas. The absence of such prevalence data limits our understanding of the causes and consequences of IDU and hampers planning efforts for IDU-related interventions. Here, we (1) describe a method of estimating IDU prevalence among non-Hispanic Black and non-Hispanic White adult residents of 95 large U.S. metropolitan statistical areas (MSAs) annually over an 11-year period (1992--2002); (2) validate the resulting prevalence estimates; and (3) document temporal trends in these prevalence estimates. IDU prevalence estimates for Black adults were calculated in several steps: we (1) created estimates of the proportion of injectors who were Black in each MSA and year by analyzing databases documenting injectors' encounters with the healthcare system; (2) multiplied the resulting proportions by previously calculated estimates of the total number of injectors in each MSA and year (Brady et al., 2008); (3) divided the result by the number of Black adults living in each MSA each year; and (4) validated the resulting estimates by correlating them cross-sectionally with theoretically related constructs (Black- and White-specific prevalences of drug-related mortality and of mortality from hepatitis C). We used parallel methods to estimate and validate White IDU prevalence. We analyzed trends in the resulting racial/ethnic-specific IDU prevalence estimates using measures of central tendency and hierarchical linear models (HLM). Black IDU prevalence declined from a median of 279 injectors per 10,000 adults in 1992 to 156 injectors per 10,000 adults in 2002. IDU prevalence for White adults remained relatively flat over time (median values ranged between 86 and 97 injectors per 10,000 adults). HLM analyses described similar trends and suggest that declines in Black IDU prevalence decelerated over time. Both sets of IDU estimates correlated cross-sectionally adequately with validators, suggesting that they have acceptable convergent validity (range for Black IDU prevalence validation: 0.27 < r < 0.61; range for White IDU prevalence: 0.38 < r < 0.80). These data give insight, for the first time, into IDU prevalence trends among Black adults and White adults in large U.S. MSAs. The decline seen here for Black adults may partially explain recent reductions in newly reported cases of IDU-related HIV evident in surveillance data on this population. Declining Black IDU prevalence may have been produced by (1) high AIDS-related mortality rates among Black injectors in the 1990s, rates lowered by the advent of HAART; (2) reduced IDU incidence among Black drug users; and/or (3) MSA-level social processes (e.g., diminishing residential segregation). The stability of IDU prevalence among White adults between 1992 and 2002 may be a function of lower AIDS-related mortality rates in this population; relative stability (and perhaps increases in some MSAs) in initiating IDU among White drug users; and social processes. Future research should investigate the extent to which these racial/ethnic-specific IDU prevalence trends (1) explain, and are explained by, recent trends in IDU-related health outcomes, and (2) are determined by MSA-level social processes.

For the common good: measuring residents' efforts to protect their community from drug- and sex-related harm

People in high-risk neighbourhoods try to protect their friends, neighbours, relatives and others from the social and physical risks associated with sex and drug use. This paper develops and validates a community-grounded questionnaire to measure such 'intravention' (health-directed efforts to protect others). An initial ethnography, including life-history interviews and focus groups, explored the forms of intravention activities engaged in by residents of Bushwick (a high-risk New York City neighbourhood). Grassroots categories of intraventions were derived and questions developed to ask about such behaviours. Face validity and adequacy of the questions were assessed by independent experts. Pre-testing was conducted, and reliability and validity were assessed. An instrument including 110 intravention items was administered to 57 community-recruited residents. Analysis focused on 57 items in 11 domain-specific subscale. All subscales had good to very good reliability; Cronbach's alpha ranged from .81 to .95. The subscales evidenced both convergent and discriminant validity. Although further testing of this instrument on additional populations is clearly warranted, this intravention instrument seems valid and reliable. It can be used by researchers in comparative and longitudinal studies of the causes, prevalence and affects of different intravention activities in communities. It can benefit public health practitioners by helping them understand the environments in which they are intervening and by helping them find ways to cooperate with local neighbourhood-level health activists.

Estimating the prevalence of injection drug users in the U.S. and in large U.S. metropolitan areas from 1992 to 2002

This paper estimates the prevalence of current injection drug users (IDUs) in 96 large U.S. metropolitan statistical areas (MSAs) annually from 1992 to 2002. Multiplier/allocation methods were used to estimate the prevalence of injectors because confidentiality restrictions precluded the use of other commonly used estimation methods, such as capture-recapture. We first estimated the number of IDUs in the U.S. each year from 1992 to 2002 and then apportioned these estimates to MSAs using multiplier methods. Four different types of data indicating drug injection were used to allocate national annual totals to MSAs, creating four distinct series of estimates of the number of injectors in each MSA. Each series was smoothed over time; and the mean value of the four component estimates was taken as the best estimate of IDUs for that MSA and year (with the range of component estimates indicating the degree of uncertainty in the estimates). Annual cross-sectional correlations of the MSA-level IDU estimates with measures of unemployment, hepatitis C mortality prevalence, and poisoning mortality prevalence were used to validate our estimates. MSA-level IDU estimates correlated moderately well with validators, demonstrating adequate convergence validity. Overall, the number of IDUs per 10,000 persons aged 15-64 years varied from 30 to 348 across MSAs (mean 126.9, standard deviation 65.3, median 106.6, interquartile range 78-162) in 1992 and from 37 to 336 across MSAs (mean 110.6, standard deviation 57.7, median 96.1, interquartile range 67-134) in 2002. A multilevel model showed that overall, across the 96 MSAs, the number of injectors declined each year until 2000, after which the IDU prevalence began to increase. Despite the variation in component estimates and methodological and component data set limitations, these local IDU prevalence estimates may be used to assess: (1) predictors of change in IDU prevalence; (2) differing IDU trends between localities; (3) the adequacy of service delivery to IDUs; and (4) infectious disease dynamics among IDUs across time.

Correlates of syringe coverage for heroin injection in 35 large metropolitan areas in the US in which heroin is the dominant injected drug

BACKGROUND

Scientific consensus holds that if, at the outset of the HIV/AIDS epidemic, injection drug users (IDUs) had had better access to sterile syringes, much of the epidemic among IDUs in the U.S. could have been prevented. In the context of preventing infectious diseases, 100% syringe coverage - that is, one sterile syringe per injector for each injection - is a public health goal. Notably, we know little about variations in syringe coverage within the U.S. and elsewhere, or about the social and political factors that might determine this coverage.

METHODS

Using data from Holmberg (1996), the 1990 United States Census, the 2000 Beth Israel National Syringe Exchange Survey (n=72), and estimates of IDUs in metropolitan areas (MSAs); (Friedman et al., 2004), we explore the impact of (1) political factors (ACT UP, outreach, early syringe exchange programme (SEP) presence, men who have sex with men (MSM) per capita, drug arrests, and police per capita); (2) local resources for SEPs; and (3) indicators of socioeconomic inequality on SEP coverage. We define "syringe coverage" as the ratio of syringes distributed at SEPs to the number of syringes heroin injectors need in a year. We calculated the number of syringes heroin injectors need in a year by multiplying an estimate of the number of IDUs in each MSA by an estimate of the average number of times heroin injectors inject heroin per year (2.8 times per day times 365 days). In this analysis, the sample was limited to 35 MSAs in which the primary drug of choice among injectors was heroin.

RESULTS

SEP coverage varies greatly across MSAs, with an average of 3 syringes distributed per 100 injection events (S.D.=0.045; range: 2 syringes per 10 injection events, to 3 syringes per 10,000 injection events). In bivariate regression analyses, a 1 unit difference in the proportion of the population that was MSM per 1000 was associated with a difference of 0.002 in SEP coverage (p=0.052); early SEP presence was associated with a difference of 0.038 in coverage (p=0.012); and having government funding was associated with a 0.040 difference in SEP coverage (p=0.021).

CONCLUSIONS

This analysis suggests that longer duration of SEP presence may increase syringe distribution and enhance successful programme utilization. Furthermore, MSAs with greater proportions of MSM tend to have better SEP coverage, perhaps providing further evidence that grassroots activism plays an important role in programme implementation and successful SEP coverage. This research provides evidence that government funding for SEPs contributes to better syringe coverage.

Positive deviance control-case life history: a method to develop grounded hypotheses about successful long-term avoidance of infection

Background

Prevalence rates for long-term injection drug users in some localities surpass 60% for HIV and 80% for HCV. We describe methods for developing grounded hypotheses about how some injectors avoid infection with either virus.

Methods

Subjects: 25 drug injectors who have injected drugs 8 – 15 years in New York City. 17 remain without antibody to either HIV or HCV; 3 are double-positives; and 5 are positive for HCV but not HIV. "Staying Safe" methodology compares serostatus groups using detailed biographical timelines and narratives; and information about how subjects maintain access to physical resources and social support; their strategies and tactics to remain safe; how they handle problems of addiction and demands by drug dealers and other drug users; and how their behaviors and strategies do or do not become socially-embedded practices. Grounded theory and life-history analysis techniques compare and contrast doubly-uninfected with those infected with both viruses or only with HCV.

Results

Themes and initial hypotheses emerging from analyses included two master hypotheses that, if confirmed, should help shape preventive interventions: 1) Staying uninfected is not simply a question of social structure or social position. It involves agency by drug injectors, including sustained hard work and adaptation to changing circumstances. 2) Multiple intentionalities contribute to remaining uninfected. These conscious goals include balancing one's need for drugs and one's income; developing ways to avoid drug withdrawal sickness; avoiding situations where other drug users importune you to share drugs; and avoiding HIV (and perhaps HCV) infection. Thus, focusing on a single goal in prevention might be sub-optimal.

Other hypotheses specify mechanisms of enacting these intentionalities. One example is finding ways to avoid extreme social ostracism.

Conclusion

We have identified strategies and tactics that some doubly-uninfected IDUs have developed to stay safe. Staying Safe methodology develops grounded hypotheses. These can be tested through cohort studies of incidence and prevention trials of hypothesis-based programs to help drug injectors make their injection and sexual careers safer for themselves and others. This positive deviance control-case life history method might be used to study avoiding other infections like genital herpes among sex workers.

Nationwide increase in the number of hospitalizations for illicit injection drug use-related infective endocarditis

Infective endocarditis is a potentially fatal consequence of illicit injection drug use. We estimate that the number of hospitalization for injection drug use-related infective endocarditis increased by 38%-66% in the United States between 2000-2001 and 2002-2003, a period during which the number of at-risk persons (i.e., injection drug users) remained stable. Increasing methamphetamine use and/or drug injection frequency may have increased the incidence of infective endocarditis among active injection drug users.

NIMBY localism and national inequitable exclusion alliances: The case of syringe exchange programs in the United States

Syringe exchange programs (SEPs) aim to reduce the harm associated with injection drug use (IDU). Although they have been accepted as critical components of HIV prevention in many parts of the world, they are often unwelcome and difficult to set up and maintain, even in communities hardest hit by IDU-related HIV transmission. This research examines socio-cultural and political processes that shape community and institutional resistance toward establishing and maintaining SEPs. These processes are configured and reinforced through the socio-spatial stigmatizing of IDUs, and legal and public policy against SEPs. Overarching themes the paper considers are: (1) institutional and/or political opposition based on (a) political and law enforcement issues associated with state drug paraphernalia laws and local syringe laws; (b) harassment of drug users and resistance to services for drug users by local politicians and police; and (c) state and local government (in)action or opposition; and (2) the stigmatization of drug users and location of SEPs in local neighborhoods and business districts. Rather than be explained by "not in my back yard" localism, this pattern seems best conceptualized as an "inequitable exclusion alliance" (IEA) that institutionalizes national and local stigmatizing of drug users and other vulnerable populations.

Some data-driven reflections on priorities in AIDS network research

Risk networks can transmit HIV or other infections; social networks can transmit social influence and thus help shape norms and behaviors. This primarily-theoretical paper starts with a review of network concepts, and then presents data from a New York network study to study patterns of sexual and injection linkages among IDUs and other drug users and nonusers, men who have sex with men, women who have sex with women, other men and other women in a high-risk community and the distribution of HIV, sex at group sex events, and health intravention behaviors in this network. It then discusses how risk network microstructures might influence HIV epidemics and urban vulnerability to epidemics; what social and other forces (such as "Big Events" like wars or ecological disasters) might shape networks and their associated norms, intraventions, practices and behaviors; and how network theory and research have and may continue to contribute to developing interventions against HIV epidemics.

Relative prevalence of different sexually transmitted infections in HIV-discordant sexual partnerships: data from a risk network study in a high-risk New York neighbourhood

OBJECTIVES

To determine infection patterns of sexually transmitted infections that facilitate HIV transmission among HIV-discordant couples.

METHODS

112 initial respondents were recruited in an impoverished neighbourhood of Brooklyn, New York. Their sexual (and injection) partners were recruited in up to four additional network sampling waves for a final sample of 465 persons aged 18 years or older. After separate informed consent had been obtained, blood and urine were collected and tested for HIV, type-specific antibodies to herpes simplex virus (HSV-2), syphilis, chlamydia and gonorrhoea.

RESULTS

Of 30 HIV-discordant partnerships, five were same-sex male partnerships and 25 were opposite-sex partnerships. No subjects tested positive for syphilis or gonorrhoea. Two couples were chlamydia-discordant. For HSV-2, 16 couples were double-positive, eight discordant, four double-negative, and two comprised a HSV-2-negative with a partner with missing herpes data.

CONCLUSIONS

HSV-2 was present in 83% of the HIV-discordant couples, chlamydia in 7%, and syphilis and gonorrhoea in none. HSV-2 is probably more important for HIV transmission than bacterial sexually transmitted diseases because it is more widespread. Even given the limited generalisability of this community-based sample, there seems to be an important HIV-prevention role for herpes detection and prevention activities in places where HIV-infected people are likely to be encountered, including sexually transmitted disease clinics, HIV counselling and testing programmes, prisons, needle exchanges, and drug abuse treatment programmes. The effects of HSV-suppressive therapy in highly impacted groups should also be investigated.

Gender differences in injection risk behaviors at the first injection episode

OBJECTIVES

To examine gender differences in drug injection equipment sharing at injecting initiation.

METHODS

Young injecting drug users (IDUs) in New York City February 1999-2003 were surveyed about injection risk behaviors and circumstances at initiation. Analyses were gender-stratified and excluded participants who initiated alone. Multiple logistic regression estimated adjusted odds ratios.

RESULTS

Participants (n=249) were 66% male and 82% White. Mean initiation age was 19.2; mean years since initiating was 3.0. Women were significantly more likely to cite social network influence as a reason for initiating, to have male and sex partner initiators, and to share injecting equipment than men. Among women, sharing any injection equipment was associated with initiation by a sex partner and having > or =2 people present. Among men, being injected by someone else predicted sharing any injection equipment, while using a legally obtained syringe was protective.

CONCLUSIONS

Social persuasion stemming from sexual and/or social relationships with IDUs may increase women's risk of sharing injection equipment at initiation, and consequently, their early parenteral risk of acquiring blood-borne infections. Interventions should focus on likely initiates, especially women in injecting-discordant sex partnerships, and IDUs (potential initiators).

Injecting and sexual risk correlates of HBV and HCV seroprevalence among new drug injectors

We examine injecting and sexual risk correlates of hepatitis B (HBV) and hepatitis C (HCV) seroprevalence among new injecting drug users (IDUs) (age 18-30 years, injecting < or =6 years). Participants were interviewed/serotested (HIVab, HBVcAb, HCVab) in New York City, February 1999-February 2003. Gender-stratified, multivariate logistic regression was conducted. Participants (N=259) were: 68% male; 81% white. Women were more likely to test HCV seropositive (42% versus 27%) and men HBV seropositive (24% versus 12%); HIV seroprevalence was low (3%). Among both men and women, HBV seropositivity was associated with ever selling sex, and HCV seropositivity with ever having had infected (HIV, HBV or HCV) sex partners (among those ever sharing injecting equipment). Among women only, HBV seropositivity was associated with ever having had infected sex partners (regardless of ever sharing injecting equipment), and HCV seropositivity with > or =300 lifetime drug injections. Among men only, HCV seropositivity was associated with > or =40 lifetime number of sex partners (among those never sharing injecting equipment). In this new IDU sample, HBV and HCV seroprevalence differed by gender and were considerably higher than HIV seroprevalence. Early interventions, targeting injecting and sexual risks and including HBV vaccination, are needed among new IDUs to prevent HBV, HCV and, potentially, HIV epidemics.

Social capital or networks, negotiations, and norms? A neighborhood case study

"Social capital" has been critiqued as distracting attention from inequalities and policies that produce ill health. We support this critique insofar as social capital refers to the degree of trust and consensus in a locality, but find value in another dimension often included in the concept of social capital--social network ties and their associated communication patterns. We present a case study of Bushwick, a community of 100,000 people in Brooklyn NY, to suggest that the network aspect of "social capital" is useful to understand the active, on-the-ground processes by which residents of some neighborhoods beset by poverty, racial/ethnic subordination, and internal divisions (that themselves arise from inequalities and state policies) work out ways to defend their own and others' safety and health. We use a combination of population-representative survey data for young adults; sexual network survey data; and ethnography to show that Bushwick residents (including drug users and dealers) have used social network ties, communication, and normative pressures to reduce the extent to which they are put at risk by the drug trade and by drug-use-related HIV/AIDS in spite of conflicting interests, disparate values, and widespread distrust both of other community members and of dominant social institutions. This was done by "intravention" health communications, development of protective norms, informal negotiations, and other forms of adjustments within and among various groups--but it occurred in the absence of trust or consensus in this community. We conclude both (1) that social network interpretations of "social capital" might be better conceptualized in dialectic terms as collective action to survive in a harsh social order, and (2) that the social capital theory emphasis on trust and consensus as important causal factors for lowering drug-related risks at the community level may be a romanticized and erroneous perspective.

The transition from injection to non-injection drug use: long-term outcomes among heroin and cocaine users in New York City

AIMS

To characterize heroin and cocaine users in New York City who have changed from injection to non-injection drug administration and to identify factors associated with long-term non-injection use.

DESIGN

Two cross-sectional studies of heroin and cocaine users in New York City.

SETTINGS AND PARTICIPANTS

New admissions were recruited at drug abuse treatment programs (2000-04) and respondent-driven sampling was used to recruit drug users from the community (2004). Both injecting and non-injecting drug users participated in each study. 'Former injectors' were defined operationally as people who had used heroin and/or cocaine in the 6 months prior to the interview and who had injected illicit drugs in the past, but whose most recent injection was more than 6 months before the study interview. 'Current' injectors were defined as people who had injected heroin and/or cocaine in the 6 months prior to the interview.

MEASUREMENTS

A structured interview on drug use history was administered, and a serum sample was collected and tested for the human immunodeficiency virus (HIV).

FINDINGS

A total of 104 former injectors was recruited for the drug abuse treatment program study, and 229 current injectors were recruited for the community recruitment study; 160 former injectors and 1731 current injectors were recruited from the drug abuse treatment study. Compared with the current injectors, former injectors were older and more likely to be African American. The former injectors reported long intervals since their most recent injection, a mean of 8 years in the drug abuse treatment program study and a mean of 12 years in the community recruitment study. The most common reasons for stopping injection drug use included concerns about health, social stigmatization and self-image, and preference for intranasal use as a route of drug administration. The results were highly consistent across the two studies.

CONCLUSIONS

The transition from injection to non-injection use appears to be relatively stable behavior change for many former injectors, who report a decade or more without injecting. Developing a greater understanding of the transition from injection to stable non-injection drug use may provide insights into the natural histories of drug use and addiction.

Social and political factors predicting the presence of syringe exchange programs in 96 US metropolitan areas

Community activism can be important in shaping public health policies. For example, political pressure and direct action from grassroots activists have been central to the formation of syringe exchange programs (SEPs) in the United States. We explored why SEPs are present in some localities but not others, hypothesizing that programs are unevenly distributed across geographic areas as a result of political, socioeconomic, and organizational characteristics of localities, including needs, resources, and local opposition. We examined the effects of these factors on whether SEPs were present in different US metropolitan statistical areas in 2000. Predictors of the presence of an SEP included percentage of the population with a college education, the existence of local AIDS Coalition to Unleash Power (ACT UP) chapters, and the percentage of men who have sex with men in the population. Need was not a predictor.

Sexual and other noninjection risks for HBV and HCV seroconversions among noninjecting heroin users

BACKGROUND

Many heroin users do not inject drugs but may still be at risk of infection with human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV), via sexual or other noninjection-related activity.

METHODS

Noninjecting heroin users (NIUs) in New York City who were recruited and prospectively followed during March 1996-February 2003 were tested for anti-HIV, anti-hepatitis B core antigen, and anti-HCV and were interviewed about their sexual and other noninjecting risk. A seroconversion is represented by the first positive test result after the last negative test result. Hazard ratios (HRs) (P<.05) were estimated by use of Cox proportional hazards regression.

RESULTS

Of 253 HIV-negative participants, 2 seroconverted (0.29/100 person-years at risk [pyar]); of 184 HBV-negative participants, 16 (3.3/100 pyar); and, of 219 HCV-negative participants, 16 (2.7/100 pyar). Independent predictors of seroconversion were, for HBV, being a female who engages in unprotected receptive anal sex (HR, 6.8), having short-term sex partners (HR, 6.2), and being a male with male sex partners (HR, 5.7); for HCV, being a male who receives money/drugs for sex (HR, 5.6) and sharing noninjecting crack-use equipment (HR, 4.5).

CONCLUSIONS

NIUs are at considerable risk of HBV infection via high-risk sex; and, for HCV, via high-risk sexual activity and the sharing of noninjecting crack-use equipment. Interventions in NIUs must seek to reduce high-risk sexual activity and the sharing of noninjecting drug-use equipment.

Convergence of HIV seroprevalence among injecting and non-injecting drug users in New York City

OBJECTIVE

To compare HIV prevalence among injecting and non-injecting heroin and cocaine users in New York City. As HIV is efficiently transmitted through the sharing of drug-injecting equipment, HIV infection has historically been higher among injecting drug users.

DESIGN

Two separate cross-sectional surveys, both with HIV counseling and testing and drug use and HIV risk behavior questionnaires.

METHODS

Injecting and non-injecting heroin and cocaine users recruited at detoxification and methadone maintenance treatment from 2001-2004 (n = 2121) and recruited through respondent-driven sampling from a research storefront in 2004 (n = 448).

RESULTS

In both studies, HIV prevalence was nearly identical among current injectors (injected in the last 6 months) and heroin and cocaine users who had never injected: 13% [95% confidence interval (CI), 12-15%] among current injectors and 12% (95% CI, 9-16%) among never-injectors in the drug treatment program study, and 15% (95% CI, 11-19%) among current injectors and 17% (95% CI, 12-21%) among never injectors in the respondent driven sampling storefront study. The 95% CIs overlapped in all gender and race/ethnicity subgroup comparisons of HIV prevalence in both studies.

CONCLUSIONS

The very large HIV epidemic among drug users in New York City appears to be entering a new phase, in which sexual transmission is of increasing importance. Additional prevention programs are needed to address this transition.

Predictors of the degree of drug treatment coverage for injection drug users in 94 metropolitan areas in the United States of America

AIMS

A prior study concluded that drug treatment coverage, defined as the percentage of injection drug users in drug treatment, varied from 1 percent to 39 percent (median 9 percent) in 96 metropolitan statistical areas (MSAs) in the United States. Here, we determine which metropolitan area characteristics are associated with drug treatment coverage.

METHODS

We conducted secondary analysis of official data, including the number of injection drug users in treatment and other variables, for 94 large US MSAs. We estimated the number of injection drug users in these metropolitan areas using previously described methods. We used lagged cross-sectional analyses where the independent variables, chosen on the basis of a Theory of Community Action, preceded the dependent variable (drug treatment coverage) in time. Predictors were determined using ordinary least squares multiple regression and confirmed with robust regression.

RESULTS

Independent predictors of higher drug treatment coverage for injectors were: presence of organisations that support treatment (unstandardized beta=1.64; 95 percent CI .59 to 2.69); education expenditures per capita in the MSA (unstandardized beta=.12; 95 percent CI -.34 to 2.69); lower percentage of drug users in treatment who are non-injection drug users (unstandardized beta=-0.18; 95 percent CI -0.24 to -0.12); higher percentage of the population who are non-Hispanic White (unstandardized beta=.14; 95 percent CI .08 to .20); lower per capita long-term debt of governments in the metropolitan area (unstandardized beta=-0.93; 95 percent CI -1.51 to -0.35).

CONCLUSIONS

In conditions of scarce treatment coverage for drug injectors, an indicator of epidemiologic need (the per capita extent of AIDS among injection drug users) does not predict treatment coverage, and competition for treatment slots by non-injectors may reduce injectors' access to treatment. Metropolitan finances limit treatment coverage. Political variables (racial structures, the presence of organisations that support drug treatment, and budget priorities) may be important determinants of treatment coverage for injectors. Although confidence in these results would be higher if we had used a longitudinal design, these results suggest that further research and action that address structural, political, and other barriers to treatment expansion are sorely needed.

New York City injection drug users' memories of syringe-sharing patterns and changes during the peak of the HIV/AIDS epidemic

In this oral history, 23 injection drug users (IDUs) were interviewed about the mid-1970s to mid-1980s when they could not legally purchase or possess syringes, and the threat of AIDS began to loom large. Several themes emerged, including: abrupt changes in syringe-sharing patterns; the effects of illnesses or deaths of others on their understanding of AIDS; and, racial/ethnic differences in responses to the threat of AIDS. Settings, such as "shooting galleries," helped HIV spread rapidly in the earliest stages of the city's AIDS epidemic. HIV entered the drug scene in the mid-1970s, just when IDUs were shifting from sharing homemade "works" (consisting of steel needles and syringes devised from rubber baby pacifiers and similar sources) among many IDUs to mass produced and distributed plastic, disposable needle and syringe sets. IDUs remember when they first became aware of AIDS and began to adjust their behaviors and social assumptions.

Residential segregation and injection drug use prevalence among Black adults in US metropolitan areas

OBJECTIVES

We analyzed the relations of two 1990 dimensions of racial residential segregation (isolation and concentration) with 1998 injection drug use prevalence among Black adult residents of 93 large US metropolitan statistical areas (MSAs).

METHODS

We estimated injection drug use prevalence among Black adults in each MSA by analyzing 3 databases documenting injection drug users' encounters with the health care system. Multiple linear regression methods were used to investigate the relationship of isolation and concentration to the natural logarithm of Black adult injection drug use prevalence, controlling for possible confounders.

RESULTS

The median injection drug use prevalence was 1983 per 100000 Black adults (interquartile range: 1422 to 2759 per 100000). The median isolation index was 0.48 (range: 0.05 to 0.84): in half the MSAs studied, the average Black resident inhabited a census tract where 48% or more of the residents were Black. The multiple regression model indicates that an increase of 0.50 in the isolation index was associated with a 23% increase in injection drug use prevalence among Black adults. Concentration was unrelated to the outcome.

CONCLUSIONS

Residential isolation is positively related to Black injection drug use prevalence in MSAs. Research into the pathways linking isolation to injection drug use is needed.

Diffusion of the D.A.R.E and syringe exchange programs

We examined the diffusion of the D.A.R.E program to reduce use of illicit drugs among school-aged children and youths and the diffusion of syringe exchange programs to reduce HIV transmission among injection drug users. The D.A.R.E program was diffused widely in the United States despite a lack of evidence for its effectiveness; there has been limited diffusion of syringe exchange in the United States, despite extensive scientific evidence for its effectiveness. Multiple possible associations between diffusion and evidence of effectiveness exist, from widespread diffusion without evidence of effectiveness to limited diffusion with strong evidence of effectiveness. The decision theory concepts of framing and loss aversion may be useful for further research on the diffusion of public health innovations.

Estimates of injecting drug users at the national and local level in developing and transitional countries, and gender and age distribution

OBJECTIVE

To present and update available national and subnational estimates of injecting drug users (IDUs) in developing/transitional countries, and provide indicative estimates of gender and age distribution.

METHODS

Literature review of both grey and published literature including updates from previously reported estimates on estimates of IDU population and data sources giving age and gender breakdowns. The scope area was developing/transitional countries and the reference period was 1998-2005.

RESULTS

Estimates of IDU numbers were available in 105 countries and 243 subnational areas. The largest IDU populations were reported from Brazil, China, India, and Russia (0.8 m, 1.9 m, 1.1 m, and 1.6 m respectively). Subnational areas with the largest IDU populations (35,000-79,000) are: Warsaw (Poland); Barnadul, Irtkustk, Nizhny-Novgorod, Penza, Voronez, St Petersburg, and Volgograd (Russia); New Delhi and Mumbai (India); Jakarta (Indonesia), and Bangkok (Thailand). By region, Eastern Europe and Central Asia have the largest IDU prevalence (median 0.65%) (min 0.3%; max 2.2%; Q1 0.39%; Q3 1.32%) [corrected] followed by Asia and Pacific: 0.24% (min 0.004%; max 1.47%; Q1 0.14%; Q3 1.47%) [corrected] In the Middle East and Africa the median value equals 0.2% (min 0.0003%; max 0.35%; Q1 0.11%; Q3 0.23%) [corrected] and in Latin America and the Caribbean: 0.12% (min 0.11%; max 0.69%; Q1 0.04%; Q3 0.13%) [corrected] Subnational areas with the highest IDU prevalence among adults (8-14.9%) were Shymkent (Kazakhstan), Balti (Moldova), Astrakhan, Barnadul, Irtkustk, Khabarovsk, Kaliningrad, Naberezhnyje Chelny, Penza, Togliatti, Volgograd, Voronez, and Yaroslavl (Russia), Dushanbe (Tajikistan), Ashgabad (Turkmenistan), Ivano-Frankivsk and Pavlograd (Ukraine) and Imphal, Manipur (India). 66% (297/447) of the IDU estimates were reported without technical information. Data on the IDU age/gender distributions are also scarce or unavailable for many countries. In 11 Eastern European and Central Asian countries the age group <or=20-29 represented >50% of the total. The proportion of IDU men was 70%-90% in Eastern Europe and Central Asia, and there was a marked absence of data on women outside this region.

CONCLUSION

Unfortunately data on IDU prevalence available to national and international policymakers is of an unknown and probably yet to be tested quality. This study provide baseline figures but steps need to be taken now to improve the reporting and assessment of these critical data.

Transitions to injecting drug use among noninjecting heroin users: social network influence and individual susceptibility

OBJECTIVES

To determine the incidence/predictors of transitions to injecting among noninjecting heroin users (NIUs).

METHODS

Street-recruited NIUs in New York City, March/1996-March/2003, were interviewed for a prospective cohort study about social network influence (communication promoting injecting; exposure to injectors) and individual susceptibility. A transition to injecting was the first drug injection following baseline. Hazards ratios (HRs) (P < 0.05) were estimated by Cox proportional hazards regression, stratified by baseline injecting history.

RESULTS

Of 369 (64% of 579) followed, former-injectors were more likely to transition to injecting (33% or 53/160 vs. 12% or 25/209; 16.0/100 person-years-at-risk [pyar] vs. 4.6/100 pyar; HR = 3.25). Independent predictors among never-injectors included using > or =2 bags of heroin daily (HR = 7.0); social network influence (communication) and homelessness (HR = 6.3); shorter-term heroin use (HR = 5.3); social network influence (exposure) and physically abused (HR = 4.7); friends approve/condone drug injecting (HR = 3.5); lower perceived social distance from injectors (HR = 2.9); and younger age at first heroin use (HR = 1.2). Independent predictors among former-injectors were social network influence (communication) and lower perceived social distance from injectors (HR = 3.4); white race/ethnicity (HR = 2.0); not very afraid of needles (HR = 1.8); and younger age (HR = 1.1).

CONCLUSIONS

The risk of initiating injecting was lower than the risk of resuming injecting. Social network influence facilitates transitioning to injecting among those susceptible. Interventions to prevent injecting should address both social network influence and individual susceptibility.