Audio-computer interviewing to measure risk behaviour for HIV among injecting drug users: a quasi-randomised trial

Predictors of change in cocaine use in a street-recruited cohort of young cocaine users

AIM

To determine predictors of changes in amount of cocaine use among regular users outside treatment services.

DESIGN

Longitudinal study-we estimated the proportion of subjects who increased or decreased cocaine use and assessed possible predictors related to these changes among a street-recruited cohort of young regular cocaine users (RCU).

SETTING

Three Spanish cities: Barcelona, Madrid and Seville

PARTICIPANTS

A total of 720 RCU aged 18-30 years not regularly using heroin were recruited in the community during 2004-06 (Itinere Project). Follow-up interviews (n = 501) were carried out at 12-24 months.

MEASUREMENTS

The average amount of cocaine used weekly was calculated taking into account the number of days of use and the usual quantity (g/day). A multinomial logistic regression approach was used to investigate the association between changes in amount of cocaine use (i.e. difference exceeded 33.3% of baseline level) after 12-24 months, and baseline socio-demographic characteristics, nightlife, patterns of cocaine use and use of alcohol and other psychoactive drugs.

FINDINGS

Cocaine use baseline average level was 2.14 g/week [95% confidence interval (CI) = 2.02-2.42]. It decreased in 71.5% of subjects and increased in 14.1%. In multinomial analysis, negative associations were found between decreasing cocaine use and high levels of alcohol consumption and using an increasing number of psychoactive drugs. Moreover, low education level, having used cocaine frequently in houses and reporting cocaine binges were associated with increasing cocaine use.

CONCLUSIONS

A street-recruited cohort of cocaine users in Spain showed a significant reduction in cocaine use over a period of 12-24 months. High consumption of alcohol and increasing use of other psychoactive drugs decreased the probability of reducing cocaine use.

Community-based electronic data collections for HIV prevention research with black/African-American men in the rural, Southern USA

In Florida, the HIV case rate among black men is five times that of white men; tailored HIV prevention interventions are lacking. Historical concerns regarding trust with public health venues and sharing sensitive information make face-to-face data collection with some rural, southern black men challenging. We evaluated the feasibility and acceptability of using audio computer-assisted self-interviews (ACASIs) by local community-based organization members to collect HIV-related information from black men in rural settings. We used logistic regression to estimate associations between using ACASI and participants' sociodemographic characteristics. Of 636 men approached, 586 (92.0%) participated, 479 (81.7%) never completed a computer survey, and 287 (71%) of those reporting a preference preferred ACASI for future data collections. Increased age, past computer use, and sharing a household with someone were significantly associated with ACASI feasibility and acceptability. Using ACASI with black men in rural settings is feasible for HIV intervention research and disparity-reducing goals.

Health and social harms associated with crystal methamphetamine use among street-involved youth in a Canadian setting

BACKGROUND AND OBJECTIVES

Despite recent increases in crystal methamphetamine use among high-risk populations such as street-involved youth, few prospective studies have examined the health and social outcomes associated with active crystal methamphetamine use.

METHODS

We enrolled 1,019 street-involved youth in Vancouver, Canada, in a prospective cohort known as the at-risk youth study (ARYS). Participants were assessed semi-annually and a generalized estimating equation (GEE) logistic regression was used to identify factors independently associated with active crystal methamphetamine use.

RESULTS

Among 1,019 participants recruited into ARYS between 2005 and 2012 the median follow up duration was 17 months, 320 (31.4%) participants were female and 454 (44.6%) had previously used crystal methamphetamine at baseline. In adjusted GEE analyses, active crystal methamphetamine use was independently associated with Caucasian ethnicity (adjusted odds ratio [AOR] = 1.37; 95% confidence interval [CI]: 1.04-1.81), homelessness (AOR = 1.34; 95% CI: 1.15-1.56), injection drug use (AOR = 3.40; 95% CI: 2.76-4.19), non-fatal overdose (AOR = 1.46; 95%CI: 1.07-2.00), being a victim of violence (AOR = 1.19; 95% CI: 1.02-1.38), involvement in sex work (AOR = 1.39; 95% CI: 1.03-1.86), and drug dealing (AOR = 1.60; 95% CI: 1.35-1.90).

DISCUSSION AND CONCLUSIONS

Prevalence of crystal methamphetamine use was high in this setting and active use was independently associated with a range of serious health and social harms.

SCIENTIFIC SIGNIFICANCE

Evidence-based strategies to prevent and treat crystal methamphetamine use are urgently needed.

Comparison of audio computer assisted self-interview and face-to-face interview methods in eliciting HIV-related risks among men who have sex with men and men who inject drugs in Nigeria

INTRODUCTION

Face-to-face (FTF) interviews are the most frequently used means of obtaining information on sexual and drug injecting behaviours from men who have sex with men (MSM) and men who inject drugs (MWID). However, accurate information on these behaviours may be difficult to elicit because of sociocultural hostility towards these populations and the criminalization associated with these behaviours. Audio computer assisted self-interview (ACASI) is an interviewing technique that may mitigate social desirability bias in this context.

METHODS

This study evaluated differences in the reporting of HIV-related risky behaviours by MSM and MWID using ACASI and FTF interviews. Between August and September 2010, 712 MSM and 328 MWID in Nigeria were randomized to either ACASI or FTF interview for completion of a behavioural survey that included questions on sensitive sexual and injecting risk behaviours. Data were analyzed separately for MSM and MWID. Logistic regression was run for each behaviour as a dependent variable to determine differences in reporting methods.

RESULTS

MSM interviewed via ACASI reported significantly higher risky behaviours with both women (multiple female sexual partners 51% vs. 43%, p = 0.04; had unprotected anal sex with women 72% vs. 57%, p = 0.05) and men (multiple male sex partners 70% vs. 54%, p≤0.001) than through FTF. Additionally, they were more likely to self-identify as homosexual (AOR: 3.3, 95%CI:2.4-4.6) and report drug use in the past 12 months (AOR:40.0, 95%CI: 9.6-166.0). MWID interviewed with ACASI were more likely to report needle sharing (AOR:3.3, 95%CI:1.2-8.9) and re-use (AOR:2.2, 95%CI:1.2-3.9) in the past month and prior HIV testing (AOR:1.6, 95%CI 1.02-2.5).

CONCLUSION

The feasibility of using ACASI in studies and clinics targeting key populations in Nigeria must be explored to increase the likelihood of obtaining more accurate data on high risk behaviours to inform improved risk reduction strategies that reduce HIV transmission.

Binge Drug Use among Street-Involved Youth in a Canadian Setting

BACKGROUND

Binge drug use has been associated with increased risk of HIV infection and other serious health-related harms among adult drug user populations. This study sought to determine the prevalence and correlates of binge drug use among street-involved youth in a Canadian setting.

METHODS

From Sept 2005 to May 2012, data were collected from the At-Risk Youth Study (ARYS), a prospective cohort of street-involved youth aged 14 - 26 who use illicit drugs. Multivariate generalized estimating equations (GEE) was used to identify factors associated with binge drug use.

RESULTS

Of the 987 participants included in this analysis, 41.5% reported binge drug use at baseline, and another 59.1% reported binge drug use at some point during the study. In multivariate GEE analysis, older age (adjusted odds ratio [AOR] = 1.11), homelessness (AOR = 1.67), drug injecting (AOR = 1.63), non-fatal overdose (AOR = 1.98), public injecting (AOR 1.42), being a victim of violence (AOR = 1.38), sex work (AOR = 2.51) and participation in drug dealing (AOR = 2.04) were independently associated with binge drug use in the previous 6 months (all p<0.05).

DISCUSSION

The prevalence of reporting binge drug use among the youth was high in this setting and was independently associated with a range of high-risk activities and markers of vulnerability. Querying high-risk youth about binge drug use may help prioritize those in greatest need of addiction treatment strategies and public health interventions.

Risk of transmission associated with sharing drug injecting paraphernalia: analysis of recent hepatitis C virus (HCV) infection using cross-sectional survey data

Sharing injecting paraphernalia (containers, filters and water) poses a risk of transmitting the hepatitis C virus (HCV). The prevalence of, and risk of HCV from, such behaviour has not been extensively reported in Europe. People who inject drugs (PWID) were recruited in cross-sectional surveys from services providing sterile injecting equipment across Scotland between 2008 and 2010. Participants completed a questionnaire and provided a blood spot for anonymous testing. Logistic regression was used to examine the association between recent HCV infection (anti-HCV negative and HCV-RNA positive) and self-reported measures of injecting equipment sharing in the 6 months preceding interview. Twelve per cent of the sample reported sharing needles/syringes, and 40% reported sharing paraphernalia in the previous 6 months. The adjusted odds ratios (AOR) for sharing needles/syringes (+/- paraphernalia), and sharing only paraphernalia in the last 6 months were 6.7 (95% CI 2.6-17.1) and 3.0 (95% CI 1.2-7.5), respectively. Among those who reported not sharing needles/syringes, sharing containers and filters were both significantly associated with recent HCV infection (AOR 3.1, 95% CI 1.3-7.8 and 3.1, 95% CI 1.3-7.5, respectively); sharing water was not. We present the first study to apply a cross-sectional approach to the analysis of the association between sharing paraphernalia and incident HCV infection and demonstrate consistent results with previous longitudinal studies. The prevalence of paraphernalia sharing in our study population is high, representing significant potential for HCV transmission.

Having "The Talk": Individual, Family, and Partner Factors on Unprotected Sex among Female Adolescent Offenders

This study assessed the influence of individual age and substance use, family support and communication, and partner support and communication on the frequency of unprotected sex among incarcerated adolescent females. Subjects (n = 273) completed a survey on psychosocial correlates and risk behaviors for sexually transmitted infections (STI). Communication with male partners and sex while under the influence have a significant impact on condom use. Findings highlight the necessity of providing assertive communication skills training and increasing self-efficacy as STI/HIV prevention components for adolescent females thus empowering their decision-making processes.

Gender and risk behaviors for HIV and sexually transmitted infections among recently released inmates: A prospective cohort study

Women in prison have a higher prevalence of HIV than men. After release from prison, former inmates have the opportunity to engage in risk behaviors for HIV and other sexually transmitted infections (STIs). We sought to assess change in risk behaviors over time and the association of gender with risk behavior in the postrelease period. In this prospective cohort study, we interviewed 200 former inmates (51 women) approximately two weeks (baseline) and three months (follow-up) after release and tested them for HIV infection at follow-up. We examined the association of gender with unprotected vaginal or anal sex in the last seven days using chi-square and Fisher's exact tests and multivariable logistic regression. At baseline, 22% of men and 41% of women reported unprotected vaginal sex (p < 0.01) and 5% of men and 8% of women reported unprotected anal sex (p = 0.51). Being younger (OR for each decade increase 0.48, 95% CI = 0.29-0.80), being gay/lesbian or being bisexual (compared with being heterosexual, OR = 4.74, 95% CI = 1.01-22.17 and OR = 3.98, 95% CI = 1.41-11.26, respectively), or reporting a drug of choice of heroin/speedballs or cocaine/crack (compared with marijuana/no drug of choice, OR = 24.00, 95% CI = 5.15-111.81 and OR = 3.49, 95% CI = 1.20-10.18, respectively) was associated with unprotected vaginal or anal sex after adjusting for race, homelessness, and hazardous drinking. At follow-up, 21% of men and 44% of women reported unprotected sex (p = 0.005), and female gender (OR = 4.42, 95% CI = 1.79-10.94) and hazardous drinking (compared with not meeting criteria for hazardous drinking, OR = 3.64, 95% CI = 1.34-9.86) were associated with unprotected sex, adjusting for race and homelessness. In this population with a high prevalence of HIV, we demonstrated persistent engagement in sexual risk behavior during the postrelease period. Enhanced efforts to promote sexual health and reduced risk behavior among both male and female current and former prison inmates are needed, including improved access to preventive care and HIV and STI screening, testing, and treatment.

Crystal methamphetamine initiation among street-involved youth

BACKGROUND

Although many settings have recently documented a substantial increase in the use of methamphetamine-type stimulants, recent reviews have underscored the dearth of prospective studies that have examined risk factors associated with the initiation of crystal methamphetamine use.

OBJECTIVES

Our objectives were to examine rates and risk factors for the initiation of crystal methamphetamine use in a cohort of street-involved youth.

METHODS

Street-involved youth in Vancouver, Canada, were enrolled in a prospective cohort known as the At-Risk Youth Study (ARYS). A total of 205 crystal methamphetamine-naïve participants were assessed semi-annually and Cox regression analyses were used to identify factors independently associated with the initiation of crystal methamphetamine use.

RESULTS

Among 205 youth prospectively followed from 2005 to 2012, the incidence density of crystal methamphetamine initiation was 12.2 per 100 person years. In Cox regression analyses, initiation of crystal methamphetamine use was independently associated with previous crack cocaine use (adjusted relative hazard [ARH] = 2.24 [95% CI: 1.20-4.20]) and recent drug dealing (ARH = 1.98 [95% CI: 1.05-3.71]). Those initiating methamphetamine were also more likely to report a recent nonfatal overdose (ARH = 3.63 [95% CI: 1.65-7.98]) and to be male (ARH = 2.12 [95% CI: 1.06-4.25]).

CONCLUSIONS

We identified high rates of crystal methamphetamine initiation among this population. Males those involved in the drug trade, and those who used crack cocaine were more likely to initiate crystal methamphetamine use. Evidence-based strategies to prevent and treat crystal methamphetamine use are urgently needed.

Application of audio computer-assisted self-interviews to collect self-reported health data: an overview

For assessment of sensitive health behaviors (e.g., sexual behavior, violent behaviors, substance use), research is typically limited to an examination of self-reports of past behavior. Audio computer-assisted self-interviews (ACASI) may enhance the validity of self-report data in research and clinical settings by reducing measurement bias. This paper provides an introduction to ACASI for collection of self-reported health data. The potential benefits and cost-effectiveness of ACASI use in research and clinical settings are reviewed. We then review the theoretical underpinnings that may underlie differential reporting of health behaviors between assessment modalities. Next, we highlight studies that have investigated differences in self-reported health behaviors between assessment modalities. Lastly, we summarize potential applications of ACASI assessments within clinical settings.

Incarceration and unstable housing interact to predict sexual risk behaviours among African American STD clinic patients

Given the dramatic racial disparities in the rates of HIV/sexually transmitted infections (STIs) among African Americans, understanding broader structural factors that increase the risk for HIV/STIs is crucial. This study investigated incarceration history and unstable housing as two structural predictors of HIV risk behaviour among 293 African Americans (159 men/134 women, mean age = 27). Participants were recruited from an urban sexually transmitted disease (STD) clinic in the southeastern U.S. Approximately half the sample had been incarcerated in their lifetime (54%), and 43% had been unstably housed in the past six months. Incarceration was independently associated with the number of sex partners and the frequency of unprotected sex. Unstable housing was independently associated with the frequency of unprotected sex. However, these main effects were qualified by significant interactions: individuals with a history of incarceration and more unstable housing had more sex partners and more unprotected sex in the past three months than individuals without these structural barriers. Implications for structural-level interventions are discussed.

Sexual risk behavior associated with transition to injection among young non-injecting heroin users

The aim of this study was to investigate the effects of transitioning from non-injection heroin use to injection drug use on sexual risk behavior. Non-injecting heroin users age 16-30 were enrolled from 2002 to 2005, and were re-interviewed at 6-month intervals for up to three years; 561 participants completed at least one follow-up interview. The majority of participants were non-Hispanic (NH) Black (54 %), 23 % were Hispanic, and 21 % were NH white. During follow-up, 154 participants (27.5 %) transitioned to injecting drugs. Logistic regression analyses were conducted using generalized estimating equations (GEE) to estimate the effect of transition to injection drug use on changes in sexual risk behavior during follow-up. Transition to injection drug use during follow-up was associated with increased likelihood of sexual risk behavior, especially for men. Harm reduction efforts that focus on preventing initiation or return to injection among non-injecting drug users may also ameliorate HIV sexual risk behaviors.

A trial of questionnaire administration modalities for measures of sexual risk behaviour in the uniformed services of Peru

Summary

Modalities of questionnaire administration may affect data quality, particularly when conducting Biological and Behavioral Surveillance Surveys (BBSS) of uniformed personnel. We aimed to examine differences in administration, reporting and data quality across several common modalities of administration for BBSS endeavors. Prior to a large-scale BBSS endeavor with the uniformed services of Peru, we pilot tested three modes of questionnaire administration among personnel engaged in internal combat: face-to-face interview (FFI), self-administered paper-based interview (SAPI), and audio computer-assisted self-interview (ACASI). Individuals who took the survey using ACASI were less likely to have missing data on measures of sexual risk and alcohol abuse and were more likely to report sexual risk behaviours and symptoms of alcohol abuse; however, more individuals took the survey using SAPI given inadequate time to devote to sitting through an entire FFI or ACASI. Sexually transmitted infections did not vary significantly across modes of questionnaire administration. While more logistically complicated for BBSS efforts in resource-constrained settings, we recommend the use of ACASI in collecting BBSS data from uniformed personnel if conditions are permissible.

Decreased injecting is associated with increased alcohol consumption among injecting drug users in northern Vietnam

BACKGROUND

Reducing injecting frequency may reduce the risk of HIV infection and improve health outcomes among injection drug users (IDUs). However, the reduction of one risk behavior may be associated with an increase in other risk behaviors, including the use of other risk-associated substances. Our objective was to determine if an association exists between a reduction in injecting and level of alcohol use among IDU.

METHODS

We conducted a longitudinal analysis of data collected for a randomized controlled trial examining the efficacy of a peer education intervention in reducing HIV risk among IDU and their network members in Thai Nguyen, Vietnam. Our analysis included active male injectors (n = 629) who were study participants and attended both baseline and 3-month visits. Frequency of alcohol consumption was assessed as the number of alcoholic drinks in the past 30 days. Change in risk and outcome behaviors was calculated as the difference in frequencies of behaviors between baseline and 3-month follow-up visits. The outcome of interest was concurrent decreased drug injection and increased alcohol consumption.

RESULTS

The mean difference between baseline and 3-month follow-up of alcohol consumption and injection frequency in the past 30 days was 19.03 drinks (93.68 SD) and 20.22 injections (35.66 SD), respectively. Participants who reported reduced injection frequency were almost three times as likely to report increased alcohol consumption (OR 2.8; 95% CI, 2.0, 4.0). The proportion that both decreased injecting and increased alcohol by any amount in the past 30 days was 35.6%. In multivariate analysis higher education was significantly associated with an increase in alcohol and decrease in injecting of any amount.

CONCLUSION

Male IDU may be at risk for increasing alcohol consumption when they reduce injection frequency. Interventions with male IDU that encourage reduction of injection may need to review specific strategies to limit alcohol consumption.

Audio computer-assisted survey instrument versus face-to-face interviews: optimal method for detecting high-risk behaviour in pregnant women and their sexual partners in the south of Brazil

Audio computer-assisted survey instrument (ACASI) has been shown to decrease under-reporting of socially undesirable behaviours, but has not been evaluated in pregnant women at risk of HIV acquisition in Brazil. We assigned HIV-negative pregnant women receiving routine antenatal care at in Porto Alegre, Brazil and their partners to receive a survey regarding high-risk sexual behaviours and drug use via ACASI (n = 372) or face-to-face (FTF) (n = 283) interviews. Logistic regression showed that compared with FTF, pregnant women interviewed via ACASI were significantly more likely to self-report themselves as single (14% versus 6%), having >5 sexual partners (35% versus 29%), having oral sex (42% versus 35%), using intravenous drugs (5% versus 0), smoking cigarettes (23% versus 16%), drinking alcohol (13% versus 8%) and using condoms during pregnancy (32% versus 17%). Therefore, ACASI may be a useful method in assessing risk behaviours in pregnant women, especially in relation to drug and alcohol use.

HCV infection prevalence lower than expected among 18-40-year-old injection drug users in San Diego, CA

San Diego, California shares the world's busiest land border crossing with Tijuana, Mexico-a city where 95 % of injection drug users (IDUs) test hepatitis C virus (HCV) antibody-positive. Yet, little is known about the prevalence and risk behaviors for HCV among IDUs in San Diego. In 2009-2010, 18-40-year-old IDUs in San Diego County completed a risk assessment interview and serologic testing for HCV and HIV infection. Recruitment involved respondent-driven sampling, venue-based sampling at a syringe exchange program, and convenience sampling. Correlates of HCV infection were identified by multivariable logistic regression. Among 510 current IDUs, 26.9 % (95 % CI 23.0-30.7 %) and 4.2 % (95 % CI 2.4-5.9 %) had been infected with HCV and HIV, respectively. Overall, median age was 28 years; 74 % were male; 60 % white and 29 % Hispanic; and 96 % were born in the U.S. Median years of injecting was 6; 41 % injected daily; 60 % injected heroin most often; 49 % receptively shared syringes and 68 % shared other injection paraphernalia; and only 22 % reported always using new syringes in the past 3 months. Two thirds had ever traveled to Mexico and 19 % injected in Mexico. HCV infection was independently associated with sharing injection paraphernalia (adjusted odds ratio [AOR] = 1.69) and SEP use (AOR = 2.17) in the previous 3 months, lifetime history of drug overdose (AOR = 2.66), and increased years of injecting (AOR = 2.82, all P values <0.05). Controlling for recruitment method did not alter results. HCV infection prevalence among IDUs in San Diego was modest compared to other US cities and much lower than Tijuana. Given that known individual-level HCV risk factors were common in San Diego, the city's lower HCV prevalence might be due to differences in social and structural factors between the cities.

Do safer sex self-efficacy, attitudes toward condoms, and HIV transmission risk beliefs differ among men who have sex with men, heterosexual men, and women living with HIV?

To understand sexual decision-making processes among people living with HIV, we compared safer sex self-efficacy, condom attitudes, sexual beliefs, and rates of unprotected anal or vaginal intercourse with at-risk partners (UAVI-AR) in the past 3 months among 476 people living with HIV: 185 men who have sex with men (MSM), 130 heterosexual men, and 161 heterosexual women. Participants were enrolled in SafeTalk, a randomized, controlled trial of a safer sex intervention. We found 15% of MSM, 9% of heterosexual men, and 12% of heterosexual women engaged in UAVI-AR. Groups did not differ in self-efficacy or sexual attitudes/beliefs. However, the associations between these variables and UAVI-AR varied within groups: greater self-efficacy predicted less UAVI-AR for MSM and women, whereas more positive condom attitudes--but not self-efficacy--predicted less UAVI-AR for heterosexual men. These results suggest HIV prevention programs should tailor materials to different subgroups.

The social and environmental context of cross-border drug use in Mexico: findings from a mixed methods study of young injection drug users living in San Diego, CA

The authors report the results of qualitative (n = 19) and quantitative (n = 545) interviews with young injection drug users (IDUs) in San Diego, California about their experiences using drugs in Tijuana, Mexico, and associated risks for HIV infection. Young IDUs who have ever traveled to Mexico (n = 365) used a variety of injection (54%) and noninjection (30%) drugs there and appear to be heavier users than those who have never traveled to Mexico. Sociocultural themes influencing drug use in Mexico included interactions among the purpose of travel, drug preference, and route of administration; familiarity with the border region; evolving relationships with the United States and Mexican drug markets; and the experience of crossing the U.S.-Mexico border. Interventions for IDUs in border regions need to be sensitive to the ethnicity, familiarity with the border region, and life history of participants, as well as differences in national policies that could influence drug use and risk for HIV on both sides of the border.

HIV rapid testing in drug treatment: comparison across treatment modalities

Despite high rates of risky behavior among patients, many drug abuse treatment programs do not provide on-site HIV testing. This secondary analysis examined differences in outcome by program modality from a multi-site trial in which 1281 HIV-negative patients in three methadone programs, seven non-methadone outpatient programs, and three residential programs were randomly assigned to: (1) off-site referral for HIV risk reduction counseling and testing; or on-site rapid testing (2) with or (3) without risk reduction counseling. The parent study using generalized estimating equations with site as a cluster variable found significantly higher rates of HIV testing and feedback of results by 1 month post-enrollment for the combined on-site conditions compared to the offsite condition [RR=4.52, 97.5% CI (3.57, 5.72)]. Utilizing the same statistical approach, we found neither significant treatment modality nor significant treatment modality by testing condition interaction effects either for receipt of HIV test results at 1 month or for sexual or drug use HIV-risk behaviors at 6-month follow-up. On-site HIV testing is effective across treatment modalities for achieving high rates of testing and results feedback. All programs should be encouraged to adopt or expand this service.

Screening for elder mistreatment in a dental clinic population

The purpose of this study was to establish the feasibility and utility of screening for elder mistreatment in a dental clinic population. We approached older adults in a busy dental clinic and enrolled 139 persons over the age of 65 who completed an Audio Computer Assisted Self Interview (ACASI), which included the Hwalek-Sengstock Elder Abuse Screening Test (HS-EAST). Overall, 48.4% of the participants scored 3 or greater on the HS-EAST, and 28.3% scored 4 or greater. Our study suggests that there is an opportunity to screen in busy dental clinics and to facilitate early detection for those patients who screen positive for elder mistreatment.

Effect of computer-assisted interviewing on self-reported sexual behavior data in a microbicide clinical trial

In a microbicide safety and effectiveness trial (HPTN 035) in Malawi, 585 women completed the same questionnaire through a face-to-face interview (FTFI) and an audio computer-assisted self-interview (ACASI). Concordance between FTFI and ACASI responses ranged from 72.0 % for frequency of sex in the past week to 95.2 % for anal intercourse (AI) in the past 3 months. Reported gel and condom use at last sex act were marginally lower with ACASI than FTFI (73.5 % vs. 77.2 %, p = 0.11 and 60.9 % vs. 65.5 %, p = 0.05, respectively). More women reported AI with ACASI than FTFI (5.0 % vs. 0.2 %, p < 0.001). Analyses of consistency of responses within ACASI revealed that 15.0 % of participants in the condom-only arm and 28.7 % in the gel arm provided at least one discrepant answer regarding total sex acts and sex acts where condom and gel were used (19.2 % reported one inconsistent answer, 8.1 % reported two inconsistent answers, and 1.4 % reported three inconsistent answers). While ACASI may provide more accurate assessments of sensitive behaviors in HIV prevention trials, it also results in a high level of internally inconsistent responses.

Effects of Promoting Health Among Teens on Dietary, Physical Activity and Substance Use Knowledge and Behaviors for African American Adolescents

BACKGROUND

African Americans are disproportionately affected by cardiovascular disease and cancer. Health promotion interventions hold promise for reducing health disparities.

PURPOSE

Promoting Health Among Teens (PHAT) is a brief, culturally tailored health education intervention to decrease cardiovascular disease and cancer risk for African Americans. This study evaluated the effects of PHAT for African American adolescents ages 14 to 17 in four eastern cities in the USA.

METHODS

A randomized controlled design (N = 1,654) was used to determine differences in health knowledge, diet, physical activity, and substance use behaviors between PHAT participants and a sexual health promotion control group. Data were collected at baseline, three, six, and twelve months post intervention. Growth curve modeling was used to detect differences in health knowledge, dietary behaviors, physical activity, and substance use between PHAT and control group participants.

RESULTS

PHAT participants had significantly greater knowledge gains but modest behavior changes compared to control group participants.

DISCUSSION

PHAT is a promising intervention to increase knowledge and address selected health behaviors in African American youth.

TRANSLATION TO HEALTH EDUCATION PRACTICE

Future attempts to execute PHAT should continue its emphasis on knowledge building while increasing intervention dosage and modifying length of time for intervention sessions.

Mediators of the relation between childhood sexual abuse and women's sexual risk behavior: a comparison of two theoretical frameworks

Childhood sexual abuse (CSA) is associated with sexual risk behavior in adulthood, but little research has investigated processes that might mediate this relation. The purpose of this study was to investigate whether constructs suggested by the traumagenic dynamics (TD) model (a theory of the effects of CSA) or constructs suggested by the information-motivation-behavioral skills (IMB) model (a theory of the antecedents of sexual risk behavior) better mediated the relation between CSA and sexual risk behavior in adulthood. Participants were 481 women attending a sexually transmitted infection clinic (66% African American) who completed a computerized survey as well as behavioral simulations assessing condom application and sexual assertiveness skills. Forty-five percent of the sample met criteria for CSA and CSA was associated with sexual risk behavior in adulthood. In multiple mediator models, the TD constructs mediated the relation between CSA and the number of sexual partners whereas the IMB constructs mediated the relation between CSA and unprotected sex. In addition, the TD constructs better mediated the relation between CSA and the number of sexual partners; the TD and IMB constructs did not differ in their ability to mediate the relation between CSA and unprotected sex. Sexual risk reduction interventions for women who were sexually abused should target not only the constructs from health behavior models (e.g., motivation and skills to reduce sexual risk), but also constructs that are specific to sexual abuse (e.g., traumatic sexualization and guilt).

Estimating the cost-effectiveness of needle-syringe programs in Australia

OBJECTIVE

To evaluate the impact and cost-effectiveness of needle-syringe programs (NSPs) with respect to HIV and hepatitis C virus (HCV) infections among Australian injecting drug users (IDUs).

DESIGN/METHODS

A health economic analysis was conducted incorporating a mathematical model of HIV and HCV transmission among IDUs. An empirical relationship between syringe availability and receptive syringe sharing (RSS) was assessed. We compared the epidemiological outcomes and costs of NSP coverage (status quo RSS of 15-17%) with scenarios that had no NSPs (RSS of 25-50%). Outcomes included numbers of HIV and HCV infections averted, lifetime health sector costs, and cost per quality-adjusted life year (QALY) gained. Discounting was applied at 3% (sensitivity: 0%, 5%) per annum.

RESULTS

We estimated that NSPs reduced incidence of HIV by 34-70% (192-873 cases) and HCV by 15-43% (19 000-77 000 cases) during 2000-2010, leading to 20 000-66 000 QALYs gained. Economic analysis showed that NSP coverage saved A$70-220 million in healthcare costs during 2000-2010 and will save an additional A$340-950 million in future healthcare costs. With NSPs costing A$245 million, the programs are very cost-effective at A$416-8750 per QALY gained. Financial investment in NSPs over 2000-2010 is estimated to be entirely recovered in healthcare cost savings by 2032 with a total future return on investment of $1.3-5.5 for every $1 invested.

CONCLUSION

Australia's early introduction and high coverage of NSPs has significantly reduced the prevalence of HIV and HCV among IDUs. NSPs are a cost-effective public health strategy and will result in substantial net cost savings in the future.

Screening for religious/spiritual struggle in blood and marrow transplant patients

PURPOSE

A growing body of research documents the harmful effects of religious/spiritual (R/S) struggle (e.g., feeling abandoned or punished by God) among patients with a wide variety of diagnoses. Documented effects include poorer quality of life, greater emotional distress, poorer recovery, and increased disability. This study reports the use of a screening protocol that identified patients who may have been experiencing R/S struggle. We also examined the prevalence and correlates of possible R/S struggle, its association with quality of life, pain, and depressive symptoms and compared the results from the screening protocol with social workers' assessments.

METHODS

One hundred seventy-eight blood and marrow transplant patients completed the Electronic Self-Report Assessment--Cancer (ESRA-C) which included the Rush Religious Struggle Screening Protocol and other measures of quality of life, pain, and depressive symptoms prior to transplant therapy. All participants were assessed by a social worker, 90 % within 2 weeks of the ESRA-C assessment.

RESULTS

Using the Rush Protocol, 18 % of the patients were identified as potentially experiencing R/S struggle. R/S struggle was not reported in any social work assessments. In a multivariable model, potential R/S struggle was more likely in patients who were more recently diagnosed, male, and Asian/Pacific Islanders. There were no significant associations between potential R/S struggle and quality of life, pain, or depressive symptoms.

CONCLUSIONS

Early identification of patients with R/S struggle will facilitate their referral for further assessment and appropriate intervention. Further research is needed to identify the best methods of screening patients for R/S struggle.

Correlates of susceptibility to hepatitis B among people who inject drugs in Sydney, Australia

Despite a safe, effective vaccine, hepatitis B virus (HBV) vaccination coverage remains low among people who inject drugs (PWID). Characteristics of participants screened for a trial investigating the efficacy of financial incentives in increasing vaccination completion among PWID were examined to inform targeting of vaccination programs. Recruitment occurred at two health services in inner-city Sydney that target PWID. HBV status was confirmed via serological testing, and questionnaires elicited demographic, drug use, and HBV risk data. Multinomial logistic regression was utilized to determine variables independently associated with HBV status. Of 172 participants, 64% were susceptible, 17% exposed (HBV core antibody-positive), and 19% demonstrated evidence of prior vaccination (HBV surface antibody ≥ 10 mIU/ml). Compared with exposed participants, susceptible participants were significantly more likely to be aged less than 35 years and significantly less likely to be receiving current opioid substitution therapy (OST) and to test hepatitis C antibody-positive. In comparison to vaccinated participants, susceptible participants were significantly more likely to be male and significantly less likely to report daily or more frequent injecting, current OST, and prior awareness of HBV vaccine. HBV vaccination uptake could potentially be increased by targeting younger, less frequent injectors, particularly young men. In addition to expanding vaccination through OST, targeting "at risk" youth who are likely to have missed adolescent catch-up programs may be an important strategy to increase coverage. The lack of an association between incarceration and vaccination also suggests increasing vaccination uptake and completion in adult and juvenile correctional facilities may also be important.

Serostatus disclosure to sexual partners among people living with HIV: examining the roles of partner characteristics and stigma

HIV serostatus disclosure among people living with HIV/AIDS (PLWHA) is an important component of preventing HIV transmission to sexual partners. Due to barriers like stigma, however, many PLWHA do not disclose their serostatus to all sexual partners. This study explored differences in HIV serostatus disclosure based on sexual behavior subgroup (men who have sex with men [MSM]; heterosexual men; and women), characteristics of the sexual relationship (relationship type and HIV serostatus of partner), and perceived stigma. We examined disclosure in a sample of 341 PLWHA: 138 MSM, 87 heterosexual men, and 116 heterosexual women who were enrolled in SafeTalk, a randomized, controlled trial of a safer sex intervention. We found that, overall, 79% of participants disclosed their HIV status to all sexual partners in the past 3 months. However, we found important differences in disclosure by subgroup and relationship characteristics. Heterosexual men and women were more likely to disclose their HIV status than MSM (86%, 85%, and 69%, respectively). Additionally, disclosure was more likely among participants with only primary partners than those with only casual or both casual and primary partners (92%, 54%, and 62%, respectively). Participants with only HIV-positive partners were also more likely to disclose than those with only HIV-negative partners, unknown serostatus partners, or partners of mixed serostatus (96%, 85%, 40%, and 60%, respectively). Finally, people who perceived more HIV-related stigma were less likely to disclose their HIV serostatus to partners, regardless of subgroup or relationship characteristics. These findings suggest that interventions to help PLWHA disclose, particularly to serodiscordant casual partners, are needed and will likely benefit from inclusion of stigma reduction components.

Development and field testing of an HIV medication touch screen computer patient adherence tool with telephone-based, targeted adherence counseling

BACKGROUND

HIV medication nonadherence is a major problem, yet many providers lack the time and training to carefully ask patients about their adherence.

OBJECTIVE

To design and pilot a technology-assisted intervention, for use in clinical settings, to identify nonadherent patients.

METHODS

The intervention uses audio computer-assisted self-interview (ACASI) to improve the assessment of adherence and medication-related problems. Patients completed a touch screen computer ACASI which generated graphic clinician and patient reports for discussion during the clinical encounter.

RESULTS

72 patients and 11 providers participated in this study. The patients easily completed the ACASI. Adherence was 63% (3-day) and 47% (30-day). Using the ACASI, 22% of patients identified themselves as nonadherent, when their providers perceived them as adherent.

CONCLUSIONS

This ACASI-based intervention is easy to use and helps identify nonadherence. The pilot test engendered enhancements including the addition of phone-based adherence counseling. A larger trial is underway to evaluate whether the intervention leads to improved HIV-related outcomes.

Police confrontations among street-involved youth in a Canadian setting

BACKGROUND

Street-level policing has been recognized as a driver of health-related harms among people who inject drugs (IDU). However, the extent of interaction between police and street-involved youth has not been well characterized. We examined the incidence and risk factors for police confrontations among street-involved youth in a Canadian setting.

METHODS

Using data derived from participants enrolled in the At-Risk Youth Study (ARYS) between 2005 and 2011, we assessed factors associated with being stopped, searched, or detained by police without arrest in the previous six months using generalized estimating equations (GEE) with logit link for binary outcomes.

RESULTS

Among 991 participants followed during the study period, 440 (44.4%) reported being stopped, searched, or detained by police for an incidence density of 49.20 (95% confidence interval [CI]: 36.42-65.01) per 100 person years. In multivariate GEE analyses, factors associated with police confrontations included: male gender (adjusted odds ratio [AOR]=1.35), homelessness (AOR=2.05), recent incarceration (AOR=1.78), daily cannabis use (AOR=1.31), daily heroin injecting (AOR=1.36), crack pipe/syringe sharing (AOR=1.61), injection drug use (AOR=1.37), public drug use (AOR=2.19), sex work involvement (AOR=1.67), and drug dealing (AOR=1.49) (all p<0.05). In total, 19.0% of participants reported that police confiscated their drug paraphernalia without arresting them. Additionally, 16.9% of individuals reported experiencing violence at the hands of police.

CONCLUSION

We found that various factors, such as homelessness and markers of more severe addiction, increased the likelihood of being confronted by police, and police confrontations were associated with markers of health-related harm among street youth. These findings highlight the need for social and structural interventions that best enable police to fulfil public safety and public order objectives without negatively influencing health behaviours of street youth.

Patterns of heroin and cocaine injection and plasma HIV-1 RNA suppression among a long-term cohort of injection drug users

BACKGROUND

Previous studies suggest that active drug use may compromise HIV treatment among HIV-positive injection drug users (IDU). However, little is known about the differential impacts of cocaine injection, heroin injection, and combined cocaine and heroin injection on plasma HIV-1 RNA suppression.

METHODS

Data were derived from a longstanding open prospective cohort of HIV-positive IDU in Vancouver, Canada. Kaplan-Meier methods and Cox proportional hazards regression were used to examine the impacts of different drug use patterns on rates of plasma HIV-1 RNA suppression.

RESULTS

Between May 1996 and April 2008, 267 antiretroviral (ART) naïve participants were seen for a median follow-up duration of 50.6 months after initiating ART. The incidence density of HIV-1 RNA suppression was 65.2 (95%CI: 57.0-74.2) per 100 person-years. In Kaplan-Meier analyses, compared to those who abstained from injecting, individuals injecting heroin, cocaine, or combined heroin/cocaine at baseline were significantly less likely to achieve viral suppression (all p<0.01). However, none of the drug use categories remained associated with a reduced rate of viral suppression when considered as time-updated variables (all p>0.05).

CONCLUSIONS

Active injecting at the time of ART initiation was associated with lower plasma HIV-1 RNA suppression rates; however, there was no difference in suppression rates when drug use patterns were examined over time. These findings imply that adherence interventions for active injectors should optimally be applied at the time of ART initiation.

Testing for amphetamine-type stimulant (ATS) use to ascertain validity of self-reported ATS use among young female sex workers in Cambodia

Objective

To assess concordance between self-reported amphetamine-type stimulant (ATS) use and toxicology results among young female sex workers (FSW) in Phnom Penh, Cambodia.

Methods

Cross-sectional data from the Young Women’s Health Study-2 (YWHS-2), a prospective study of HIV and ATS use among young (15 to 29 years) FSW in Phnom Penh, Cambodia, was analyzed. The YWHS-2 assessed sociodemographic characteristics, HIV serology, HIV risk, and ATS use by self-report and urine toxicology testing at each quarterly visit, the second of which provided data for this assessment. Outcomes include sensitivity, specificity, positive- and negative predictive values (overall and stratified by age), sex-work setting, and HIV status.

Results

Among 200 women, prevalence of positive toxicology screening for ATS use was 14% (95% confidence interval [CI], 9.2, 18.9%) and concurrent prevalence of self-reported ATS was 15.5% (95% CI, 10.4, 20.6%). The sensitivity and specificity of self-reported ATS use compared to positive toxicology test results was 89.3% (25/28), and 96.5% (166/172), respectively. The positive predictive value of self-reported ATS use was 80.6% (25/31); the negative predictive value was 98.2% (166/169). Some differences in concordance between self-report and urine toxicology results were noted in analyses stratified by age group and sex-work setting but not by HIV status.

Conclusion

Results indicate a high prevalence of ATS use among FSW in Phnom Penh, Cambodia, and high concordance between self-reported and toxicology-test confirmed ATS use.

Advances in the psychosocial treatment of addiction: the role of technology in the delivery of evidence-based psychosocial treatment

The clinical community has a growing array of psychosocial interventions with a strong evidence base available for the treatment of SUDs. Considerable opportunity exists for leveraging technology in the delivery of evidence-based interventions to promote widespread reach and impact of evidence-based care. Data from this line of research to date are promising, and underscore the potential public health impact of technology-based therapeutic tools. To fully realize the potential of technology-delivered interventions, several areas of inquiry remain important. First, scientifically sound strategies should be explored to ensure technology-based interventions are optimally designed to produce maximal behavior change. Second, efficient and effective methods should be identified to integrate technology-based interventions into systems of care in a manner that is most responsive to the needs of individual users. Third, payment, privacy, and regulatory systems should be refined and extended to go beyond electronic medical records and telehealth/distance care models, and support the deployment of technology-based systems to enhance the quality, efficiency and cost-effectiveness of care. Fourth, the mechanisms underlying behavior change derived from technology-based treatments should be explicated, including new mechanisms that may be tapped via novel, technology-based tools. Such work will be critical in isolating mechanisms that are useful in predicting treatment response, and in ensuring that key ingredients are present in technology-based interventions as they are made widely available.

A survey of condom use behaviors and HIV/STI prevalence among venue-based money boys in Shenzhen, China

We examined an at-risk population in China, money boys (MBs), to evaluate their potential role for transmitting HIV and sexually transmitted infections (STIs). Data were collected from 418 MBs selected by time-location cluster sampling, using a self-administered computerized questionnaire and testing a small blood sample for HIV/STIs. One-third (32.1%) of participants self-identified as homosexual, 25.4% heterosexual, 33.5% bisexual, and 9.1% uncertain. Consistent condom use by participants was 70-80% with commercial sex partners, 43.9% with girlfriends, and 60-70% with other non-commercial partners. HIV prevalence was 3.3%; syphilis, 10.5%; and HSV-2, 11.0%; overall prevalence for any was 20.3%. Factors significantly associated with HIV/STIs included being minority (OR = 4.82), having only male partners (OR = 1.92), having more male casual partners in the last 6 months (OR = 1.28), being younger at sexual debut (OR = 1.14), and being older (OR = 1.11). This study emphasizes the importance of developing targeted interventions for MBs, particularly those who are homosexual or minority.

Computerized assessment facilitates disclosure of sensitive HIV risk behaviors among African Americans entering substance abuse treatment

BACKGROUND

Individuals entering substance abuse treatment are at elevated risk for HIV infection, and clinicians must generally rely on patient self-report to gauge their involvement in risk behaviors. Strategies to improve accurate reporting of personally sensitive or stigmatizing risk behaviors are needed.

OBJECTIVE

This study compared computerized and face-to-face interview methods in eliciting self-disclosure of HIV risk behaviors among a high-risk sample of urban African Americans entering substance abuse treatment (N = 146).

METHODS

Participants completed a standardized HIV risk behavior screening as a face-to-face interview. Several days later, the same participants completed a computerized self-interview with the same measure, covering the same time frame.

RESULTS

Disclosure rates for many sensitive risk behaviors were considerably higher on the computerized interview. Participants had significantly higher odds of disclosure on the computerized interview compared to the face-to-face interview on 2 of 6 drug risk behaviors examined (ORs between 2.75 and 3.15) and 9 of 13 sex risk behaviors examined (ORs between 1.60 and 6.45). The advantage of the computerized interview was most evident for highly stigmatized behaviors, such as unprotected sex with someone other than a spouse or main partner (OR = 3.93; p < .001), unprotected sex during a commercial sex transaction (OR = 5.63; p < .001), unprotected anal sex (OR = 6.45; p < .001), and using unsterilized syringes (OR = 3.15; p < .05).

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Findings support the utility of computerized risk behavior assessment with African Americans entering substance abuse treatment. Computerized assessment of HIV risk behaviors may be clinically useful in substance abuse treatment and other healthcare venues serving high-risk populations.

Factors associated with difficulty accessing crack cocaine pipes in a Canadian setting

INTRODUCTION AND AIMS

Crack cocaine pipe sharing is associated with various health-related harms, including hepatitis C transmission. Although difficulty accessing crack pipes has been found to predict pipe sharing, little is known about the factors that limit pipe access in settings where pipes are provided at no cost, albeit in limited capacity. Therefore, we investigated crack pipe access among people who use drugs in Vancouver, Canada.

DESIGN AND METHODS

Data were collected through two Canadian prospective cohort studies. Generalised estimating equations with logit link for binary outcomes were used to identify factors associated with difficulty accessing crack pipes.

RESULTS

Among 914 participants who reported using crack cocaine, 33% reported difficulty accessing crack pipes. In multivariate analyses, factors independently associated with difficulty accessing crack pipes included: sex work involvement [adjusted odds ratio (AOR) = 1.57; 95% confidence interval (CI): 1.03-2.39], having shared a crack pipe (AOR = 1.69; 95% CI: 1.32-2.16), police presence where one buys/uses drugs (AOR = 1.47; 95% CI: 1.10-1.95), difficulty accessing services (AOR = 1.74; 95% CI: 1.31-2.32) and health problems associated with crack use (AOR = 1.37; 95% CI: 1.04-1.79). Reasons given for difficulty accessing pipes included sources being closed (48.2%) and no one around selling pipes (18.1%).

DISCUSSION AND CONCLUSIONS

A substantial proportion of people who smoke crack cocaine report difficulty accessing crack pipes in a setting where pipes are available at no cost but in limited quantity. These findings indicate the need for enhanced efforts to distribute crack pipes and address barriers to pipe access.

Relationships between self-reported smoking, household environmental tobacco smoke exposure and depressive symptoms in a pregnant minority population

This study sought to examine relationships between depressive symptoms and prenatal smoking and/or household environmental tobacco smoke exposure (HH-ETSE) among urban minority women. We analyzed private, audio computer-assisted self interview data from a clinic-based sample of 929 minority pregnant women in Washington, DC. Depressive symptoms were assessed via the Beck Depression Inventory Fast Screen. HH-ETSE, current smoking, and former smoking were assessed via self-report. Depression levels and demographic characteristics were compared: (1) among nonsmokers, for those reporting HH-ETSE versus no HH-ETSE; and (2) among smokers, for those reporting current smoking (in last 7 days) versus former smokers. Measures associated with HH-ETSE/current smoking in bivariate analysis at P < 0.20 were included in adjusted logistic regression models. HH-ETSE, as a possible indicator of a social smoking network, was assessed as a mediator for the relationship between depression and current smoking.

RESULTS

Non-smokers reporting moderate-to-severe depressive symptoms showed significantly higher adjusted odds of prenatal HH-ETSE (AOR 2.5, 95% CI [1.2, 5.2]). Smokers reporting moderate-to-severe or mild depressive symptoms showed significantly higher adjusted odds of current smoking (AOR 1.9, 95% CI [1.1, 3.5] and AOR 1.8, 95% CI [1.1, 3.1], respectively). Among smokers, HH-ETSE was a significant mediator for the association between moderate-to-severe symptoms and current smoking. In conclusion, health care providers should be aware that depressed urban minority women are at risk of continued smoking/HH-ETSE during pregnancy. Interventions designed to encourage behavior change should include screening for depression, and build skills so that women are better able to address the social environment.

'I've had unsafe sex so many times why bother being safe now?': the role of cognitions in sexual risk among American Indian/Alaska Native men who have sex with men

BACKGROUND

American Indian/Alaska Native (AI/AN) men who have sex with men (MSM) are at high risk of human immunodeficiency virus (HIV) acquisition and transmission.

PURPOSE

This study aimed to investigate a potential area of focus for HIV prevention interventions by assessing the impact of sexual risk cognitions on sexual risk-taking among AI/AN MSM.

METHODS

AI/AN MSM (N = 173) from a national cross-sectional survey were analyzed.

RESULTS

Reporting more frequent sexual risk cognitions overall (high sexual risk cognitions) was associated with multiple HIV risk factors including unprotected anal intercourse and serodiscordant unprotected anal intercourse. Participants with high sexual risk cognitions had a 2.3 (95% Confidence Interval: 1.1, 4.7) times greater odds of engaging in unprotected anal intercourse regardless of childhood sexual abuse, depression, and alcohol dependence. Most individual sexual risk cognitions were associated with unprotected anal intercourse, serodiscordant unprotected anal intercourse, or both.

CONCLUSIONS

Results suggest that sexual risk cognitions may be a productive area for further work on HIV prevention among AI/AN MSM.

Design and methodological considerations of an effectiveness trial of a computer-assisted intervention: an example from the NIDA Clinical Trials Network

Computer-assisted interventions hold the promise of minimizing two problems that are ubiquitous in substance abuse treatment: the lack of ready access to treatment and the challenges to providing empirically-supported treatments. Reviews of research on computer-assisted treatments for mental health and substance abuse report promising findings, but study quality and methodological limitations remain an issue. In addition, relatively few computer-assisted treatments have been tested among illicit substance users. This manuscript describes the methodological considerations of a multi-site effectiveness trial conducted within the National Institute on Drug Abuse's (NIDA's) National Drug Abuse Treatment Clinical Trials Network (CTN). The study is evaluating a web-based version of the Community Reinforcement Approach, in addition to prize-based contingency management, among 500 participants enrolled in 10 outpatient substance abuse treatment programs. Several potential effectiveness trial designs were considered and the rationale for the choice of design in this study is described. The study uses a randomized controlled design (with independent treatment arm allocation), intention-to-treat primary outcome analysis, biological markers for the primary outcome of abstinence, long-term follow-up assessments, precise measurement of intervention dose, and a cost-effectiveness analysis. Input from community providers during protocol development highlighted potential concerns and helped to address issues of practicality and feasibility. Collaboration between providers and investigators supports the utility of infrastructures that enhance research partnerships to facilitate effectiveness trials and dissemination of promising, technologically innovative treatments. Outcomes from this study will further the empirical knowledge base on the effectiveness and cost-effectiveness of computer-assisted treatment in clinical treatment settings.

The effect of changes in condom usage and antiretroviral treatment coverage on human immunodeficiency virus incidence in South Africa: a model-based analysis

This study aims to assess trends in human immunodeficiency virus (HIV) incidence in South Africa, and to assess the extent to which prevention and treatment programmes have reduced HIV incidence. Two models of the South African HIV epidemic, the STI (sexually transmitted infection)-HIV Interaction model and the ASSA2003 AIDS and Demographic model, were adapted. Both models were fitted to age-specific HIV prevalence data from antenatal clinic surveys and household surveys, using a Bayesian approach. Both models suggest that HIV incidence in 15-49 year olds declined significantly between the start of 2000 and the start of 2008: by 27 per cent (95% CI: 21-32%) in the STI-HIV model and by 31 per cent (95% CI: 23-39%) in the ASSA2003 model, when expressed as a percentage of incidence rates in 2000. By 2008, the percentage reduction in incidence owing to increased condom use was 37 per cent (95% CI: 34-41%) in the STI-HIV model and 23 per cent (95% CI: 14-34%) in the ASSA2003 model. Both models also estimated a small reduction in incidence owing to antiretroviral treatment by 2008. Increased condom use therefore appears to be the most significant factor explaining the recent South African HIV incidence decline.

Directly observed antiretroviral therapy eliminates adverse effects of active drug use on adherence

BACKGROUND

The impact of adherence enhancing interventions on the relationship between active drug use and adherence is largely unknown.

METHODS

We conducted a 24-week randomized controlled trial of antiretroviral directly observed therapy (DOT) vs. treatment as usual (TAU) among HIV-infected methadone patients. Our outcome measure was pill count antiretroviral adherence, and our major independent variables were treatment arm (DOT vs. TAU) and active drug use (opiates, cocaine, or both opiates and cocaine). We defined any drug use as ≥ 1 positive urine toxicology result, and frequent drug use as ≥ 50% tested urines positive. We used mixed-effects linear models to evaluate associations between adherence and drug use, and included a treatment arm-by-drug use interaction term to evaluate whether DOT moderates associations between drug use and adherence.

RESULTS

39 participants were randomized to DOT and 38 to TAU. We observed significant associations between adherence and active drug use, but these were limited to TAU participants. Adherence was worse in TAU participants with any opiate use than in TAU participants without (63% vs. 75%, p<0.01); and worse among those with any polysubstance (both opiate and cocaine) use than without (60% vs. 73%, p=0.01). We also observed significant decreases in adherence among TAU participants with frequent opiate or frequent polysubstance use, compared to no drug use. Among DOT participants, active drug use was not associated with worse adherence.

CONCLUSIONS

Active opiate or polysubstance use decreases antiretroviral adherence, but the negative impact of drug use on adherence is eliminated by antiretroviral DOT.

Patient reported outcomes in routine care: advancing data capture for HIV cohort research

INTRODUCTION

Computerized collection of standardized measures of patient reported outcomes (PROs) provides a novel paradigm for data capture at the point of clinical care. Comparisons between data from PROs and Electronic Health Records (EHR) are lacking. We compare EHR and PRO for capture of depression and substance abuse and their relationship to adherence to antiretroviral therapy (ART).

METHODS

This retrospective study includes HIV-positive patients at an HIV clinic who completed an initial PRO assessment April 2008-July 2009. The questionnaire includes measures of depression (PHQ-9) and substance abuse (ASSIST). Self-reported ART adherence was modeled using separate logistic regression analyses (EHR vs PRO).

RESULTS

The study included 782 participants. EHR vs PRO diagnosis of current substance abuse was 13% (n = 99) vs 6% (n = 45) (P < .0001), and current depression was 41% (n = 317) vs 12% (n = 97) (P < .0001). In the EHR model, neither substance abuse (OR = 1.25; 95% CI = 0.70-2.21) nor depression (OR = 0.93; 95% CI = 0.62-1.40) was significantly associated with poor ART adherence. Conversely, in the PRO model, current substance abuse (OR = 2.78; 95% CI = 1.33-5.81) and current depression (OR = 1.93; 95% CI = 1.12-3.33) were associated with poor ART adherence.

DISCUSSIONS

The explanatory characteristics of the PRO model correlated best with factors known to be associated with poor ART adherence (substance abuse; depression). The computerized capture of PROs as a part of routine clinical care may prove to be a complementary and potentially transformative health informatics technology for research and patient care.

Chronic hepatitis C virus infection and increases in viral load in a prospective cohort of young, HIV-uninfected injection drug users

BACKGROUND

Chronic hepatitis C (HCV) infection, defined as persistent RNA (viral load) for at least 6 months, accounts for up to 50% of all cirrhosis, end-stage liver disease and liver cancer cases. Moreover, elevated HCV viral load is consistently associated with high infectivity and poor therapy response. This study aims to identify modifiable behavioral correlates both chronic HCV infection and increases in viral load over time among injection drug users (IDUs).

METHODS

Cross-sectional and longitudinal analyses were performed using self-interview and serological data from a prospective cohort study (2002-2006) among young (age 18-35), HIV-negative, HCV therapy-naïve IDUs (n=113) from metropolitan Chicago, Illinois, USA.

RESULTS

After adjustment for age, gender and race/ethnicity, using drugs measured or mixed in someone else's syringe (odds ratio=2.7, 95% confidence interval: 1.1, 6.7) was associated with chronic (n=75, 66%) versus resolved (n=38, 34%) HCV infection status. Among chronically-infected IDUs, injecting with a new, sterile syringe infrequently (<1/2 half the time when injecting) compared to frequently (1/2 the time or more when injecting) was associated with increases in viral load over time after adjusting for age, gender, race/ethnicity and time effects.

CONCLUSIONS

Reductions in risky injection-related practices among young IDUs may ameliorate both the burden of chronic HCV infection-related liver disease and elevated viral load-related poor treatment response.

Sex parties among young gay, bisexual, and other men who have sex with men in New York City: attendance and behavior

Very little information exists with regard to sex party behaviors in young men who have sex with men (YMSM), often defined as men ranging in age from 13 to 29 years. The current analysis examines sex party attendance and behavior in a sample of 540 emergent adult gay, bisexual, and other YMSM in New York City, ages 18-29 years. Findings indicate that 8.7% (n = 47) of the sample had attended a sex party 3 months prior to assessment. Sex party attendees reported that parties included both HIV-positive and HIV-negative men; attendees also reported unprotected sex and limited access to condoms and lubricant. As compared with those who did not attend sex parties, those who did indicated significantly more lifetime and recent (last 3 months) casual sex partners, drug use (both number of different drugs used and total lifetime use), psychosocial burden (history of partner violence and number of arrests), and total syndemic burden (a composite of unprotected anal sex, drug use and psychosocial burden). These results indicate that while only a small percentage of the overall sample attended sex parties, the intersection of both individual risk factors coupled with risk factors engendered within the sex party environment itself has the potential to be a catalyst in the proliferation of the HIV/AIDS epidemic in urban settings. Lastly, given that sex parties are different than other sex environments, commercial and public, with regard to how they are accessed, public health strategies may need to become more tailored in order to reach this potentially highly risky group.

Drug dealing cessation among a cohort of drug users in Vancouver, Canada

INTRODUCTION

Drug dealing among drug users has been associated with elevated risk-taking and negative health outcomes. However, little is known about the cessation of drug dealing among this population.

METHODS

We assessed time to cessation of drug dealing using Cox regression. We also used generalized estimating equation (GEE) analysis and chi-square analysis to examine factors associated with willingness to cease drug dealing.

RESULTS

In total, 868 participants reported drug dealing between November 2005 and March 2009. Among 381 participants dealing drugs at baseline, 194 (51%) ceased dealing. Incidence of dealing cessation was positively associated with spending less than $50 per day on drugs (Adjusted Hazard Ratio [AHR]=1.88, 95% confidence interval [CI]: 1.14-3.10) and negatively associated with buying drugs from the same source (AHR=0.60, 95% CI: 0.37-0.98). In a GEE analysis, willingness to cease dealing was positively associated with older age (Adjusted Odds Ratio [AOR]=1.02, 95% CI: 1.01-1.03), crack use (AOR=2.00, 95% CI: 1.44-2.79), public injecting (AOR=1.95, 95% CI: 1.55-2.43), and reporting that police presence affects drug purchases (AOR=1.53, 95% CI: 1.22-1.91), and negatively associated with crystal methamphetamine injection (AOR=0.62, 95% CI: 0.47-0.83).

DISCUSSION

Intensity of drug use and acquisition method were predictive of dealing cessation. Willingness to cease dealing was associated with a range of risky drug-related activities. Interventions to reduce drug dealing should be conceived in tandem with addiction treatment strategies.